Position of the American Dietetic Association and American Society for Nutrition: Obesity, Reproduction, and Pregnancy Outcomes

Cellular and molecular overview of gestational diabetes mellitus: Is it predictable and preventable?

BACKGROUND

In contrast to overt diabetes mellitus (DM), gestational DM (GDM) is defined as impaired glucose tolerance induced by pregnancy, which may arise from exaggerated physiologic changes in glucose metabolism. GDM prevalence is reported to be as high as 20% among pregnancies depending on the screening method, gestational age, and the population studied. Maternal and fetal effects of uncontrolled GDM include stillbirth, macrosomia, neonatal diabetes, birth trauma, and subsequent postpartum hemorrhage. Therefore, it is essential to find the potential target population and associated predictive and preventive measures for future intensive peripartum care.

AIM

To review studies that explored the cellular and molecular mechanisms of GDM as well as predictive measures and prevention strategies.

METHODS

The search was performed in the Medline and PubMed databases using the terms “gestational diabetes mellitus,” “overt diabetes mellitus,” and “insulin resistance.” In the literature, only full-text articles were considered for inclusion (237 articles). Furthermore, articles published before 1997 and duplicate articles were excluded. After a final review by two experts, all studies (1997-2023) included in the review met the search terms and search strategy (identification from the database, screening of the studies, selection of potential articles, and final inclusion).

RESULTS

Finally, a total of 79 articles were collected for review. Reported risk factors for GDM included maternal obesity or overweight, pre-existing DM, and polycystic ovary syndrome. The pathophysiology of GDM involves genetic variants responsible for insulin secretion and glycemic control, pancreatic β cell depletion or dysfunction, aggravated insulin resistance due to failure in the plasma membrane translocation of glucose transporter 4, and the effects of chronic, low-grade inflammation. Currently, many antepartum measurements including adipokines (leptin), body mass ratio (waist circumference and waist-to-hip ratio], and biomarkers (microRNA in extracellular vesicles) have been studied and confirmed to be useful markers for predicting GDM. For preventing GDM, physical activity and dietary approaches are effective interventions to control body weight, improve glycemic control, and reduce insulin resistance.

CONCLUSION

This review explored the possible factors that influence GDM and the underlying molecular and cellular mechanisms of GDM and provided predictive measures and prevention strategies based on results of clinical studies.

Effects of intensive nutrition education and counseling on nutritional status of pregnant women in East Shoa Zone, Ethiopia

Background

Nutritional status is defined as an individual's health condition as it is influenced by the intake and utilization of nutrients. Maternal malnutrition is widespread throughout the world, with Sub-Saharan Africa and Asia bearing the brunt of the burden. The objective of this study was to evaluate the effect of intensive nutrition education and counseling on nutritional status during pregnancy.

Methods and materials

The study was a one-year, two-arm parallel design cluster randomized controlled trial conducted in the East Shoa zone, Ethiopia, from January 1, 2021, to February 30, 2022. A total of 374 participants were enrolled in the intervention (n = 185) and control (n = 189) groups. End-line data were collected from 163 women, from each group. The intervention package provided three counseling sessions by trained midwives, three-page take-home brochures prepared in local languages, and the delivery of 18 weekly serial short text messages. The women in the control group received routine nutrition education from the health facilities. After adjusting for potential confounders, a linear mixed-effects model was employed to assess the intervention effect.

Results

After the intervention, the mean mid-upper arm circumference in the intervention group increased by 1.8% (23.08 vs. 23.44, p < 0.01). Similarly, the proportion of undernutrition in the intervention group was 11% (25 vs. 36%, p = 0.02) lower compared to the control arm. At the end of the trial, women in the intervention arm had significantly better nutritional status than women in the control group (β = 0.47, p < 0.01).

Conclusion

The findings showed that intensive nutrition education and counseling using the health belief model was effective in improving nutritional status and reducing undernutrition among pregnant women. As a result, nutrition education and counseling using HBM constructs, as well as regular reminder messages, should be provided to pregnant women as part of the routine antenatal care service.

Quality Appraisal of Nutritional Guidelines to Prevent, Diagnose, and Treat Malnutrition in All Its Forms during Pregnancy

This work aimed to identify clinical practice guidelines (CPGs) that include recommendations for the prevention, diagnosis, and treatment of women’s malnutrition during pregnancy and to evaluate the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. We conducted a literature review using PubMed and different websites from January 2009 to February 2021. The quality of the CPGs was independently assessed by reviewers using the AGREE II instrument, which defines guidelines scoring >70% in the overall assessment as “high quality”. The analysis included 43 guidelines. Among the main findings, we identified that only half of the CPGs (51.1%) obtained a final “high quality” evaluation. AGREE II results varied widely across domains and categories. The two domains that obtained the highest scores were scope and purpose with 88.3% (range 39 to 100%) and clarity of presentation with 87.2% (range 25 to 100%). Among the “high quality” CPGs, the best scores were achieved by the three guidelines published by the National Institute of Health and Care Excellence (NICE) and the World Health Organization (WHO). Due to the importance of maternal nutrition in pregnancy, it is essential to join forces to improve the quality of the guidelines, especially in CPGs that do not meet the reference standards for quality.

Protocol of the Fit-For-Fertility study: a multicentre randomised controlled trial assessing a lifestyle programme targeting women with obesity and infertility

INTRODUCTION

Women with obesity are at a higher risk of infertility as well as gestational and neonatal complications. Lifestyle changes are universally recommended for women with obesity seeking fertility treatments, but such intervention has only been assessed in very few robust studies. This study's objectives are therefore to assess the clinical outcomes and cost-effectiveness of an interdisciplinary lifestyle intervention (the Fit-For-Fertility Programme; FFFP) targeting women with obesity and subfertility in a diverse population.

METHODS AND ANALYSIS

This pragmatic multicentre randomised controlled trial (RCT) will include 616 women with obesity (body mass index ≥30 kg/m² or ≥27 kg/m² with polycystic ovary syndrome or at-risk ethnicities) who are evaluated at a Canadian fertility clinic for subfertility. Women will be randomised either to (1) the FFFP (experimental arm) alone for 6 months, and then in combination with usual care for infertility if not pregnant; or (2) directly to usual fertility care (control arm). Women in the intervention group benefit from the programme up to 18 months or, if pregnant, up to 24 months or the end of the pregnancy (whichever comes first). Women from both groups are evaluated every 6 months for a maximum of 18 months. The primary outcome is live birth rate at 24 months. Secondary outcomes include fertility, pregnancy and neonatal outcomes; lifestyle and anthropometric measures; and cost-effectiveness. Qualitative data collected from focus groups of participants and professionals will also be analysed.

ETHICS AND DISSEMINATION

This research study has been approved by the Research Ethics Board (REB) of Centre intégré universtaire de santé et des services sociaux de l'Estrie-CHUS (research coordinating centre) on 10 December 2018 and has been or will be approved successively by each participating centres' REB. This pragmatic RCT will inform decision-makers on improving care trajectories and policies regarding fertility treatments for women with obesity and subfertility.

TRIAL REGISTRATION NUMBER

NCT03908099.

PROTOCOL VERSION

1.1, 13 April 2019.

Nutrition as Prevention Factor of Gestational Diabetes Mellitus: A Narrative Review

Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder with onset or first recognition during pregnancy. GDM is associated with several adverse maternal and neonatal outcomes. Management to reduce the incidence of GDM could decrease the incidence of these complications. Modification of nutrition in the prevention of GDM is postulated. The vital issue in GDM prevention is the implementation of proper dietary patterns, appropriate physical activity, and a combination of diet and lifestyle modifications. However, intervention studies examining the effects of diet and lifestyle on GDM prevention are contradictory. The aim of this study was to review the scientific evidence on nutritional prevention strategies, including diet and supplementation of some substances such as probiotics, micro/macroelements, fiber, myoinositol, and vitamins that may be effective in reducing the risk of GDM. The presented article is a narrative review. This article indicates that certain nutritional factors may have some benefit in preventing GDM. However, further studies in a variety of populations and large groups of patients are needed. At present, no definitive conclusions can be drawn as to the best intervention in the prevention of GDM.

Decrease in sweet taste response and T1R3 sweet taste receptor expression in pregnant mice highlights a potential mechanism for increased caloric consumption in pregnancy

While much is known on how the maternal diet affects offspring fitness, less is known on the role of taste in guiding and promoting food intake during this crucial period. Women have intense food cravings and exhibit altered taste preferences during pregnancy, however the mechanistic details underlying these changes are presently unclear. We performed longitudinal brief-access taste testing in female mice before, during, and after pregnancy, along with quantitative PCR on taste buds and morphological analysis of taste tissues from pregnant and non-pregnant mice. Sucrose licking response decreased progressively during pregnancy compared to that prior to mating, with partial recovery in the post-partum period. No change in taste morphology was evident between pregnant and non-pregnant mice, however a notable decrease in T1R3 sweet taste receptor mRNA expression was recorded in pregnant dams. We conclude that altered taste preferences during pregnancy likely result from changes in the expression profile of taste buds in the mother, which may promote a less healthy diet while expecting.

Perceived Motivators, Barriers and Intervention Strategies Related to Weight Loss After Childbirth Among WIC Participants in Southern California

PURPOSE

To explore perceived motivators and barriers to weight loss after childbirth and ideas for postpartum weight loss interventions among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

APPROACH

Four (2 with English-speaking and 2 with Spanish-speaking participants) focus groups were conducted.

SETTING

A WIC clinic in Southern California.

PARTICIPANTS

Of 22 participants, the majority were Hispanic/Latina. The mean age of the mothers' infants was 6.18 months.

MEASURES

A structured focus group guide was used.

ANALYSIS

Audio-recordings were transcribed verbatim. The Spanish transcriptions were reviewed for discrepancies by a bilingual coinvestigator and translated into English for analysis. Transcriptions of the focus group audio-recordings were organized in ATLAS.ti version 8.0. and analyzed using content analysis.

RESULTS

Participants had a mean age of 30.5 and a mean prepregnancy body mass index of 32.4. Motivators for weight loss after childbirth included modeling healthy behavior for children and a fear of developing chronic illness. Barriers to weight loss included lack of knowledge, self-efficacy, time, child care and support, postpartum depression, the 40-day rule, and having a c-section. Intervention ideas included providing accountability and peer support for weight loss, providing nutrition/exercise weight loss strategies, and integrating mobile phone technologies into weight loss programs.

CONCLUSIONS

Weight loss strategies for postpartum WIC participants should provide knowledge, support, accountability, and preferably integrate technology.

Obesity and Reproduction

OBJECTIVE

To provide a comprehensive review and evidence-based recommendations for the delivery of fertility care to women with obesity.

OUTCOMES

The impact of obesity on fertility, fertility treatments, and both short and long-term maternal fetal outcomes was carefully considered.

EVIDENCE

Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and key words. Results included systematic reviews, clinical trials, observational studies, clinical practice guidelines, and expert opinions.

VALUES

The Canadian Fertility & Andrology Society (CFAS) is a multidisciplinary, national non-profit society that serves as the voice of reproductive specialists, scientists, and allied health professionals working in the field of assisted reproduction in Canada. The evidence obtained for this guideline was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committee of the CFAS under the leadership of the principal authors.

BENEFITS, HARMS, AND COSTS

The implementation of these recommendations should assist clinicians and other health care providers in counselling and providing reproductive care to women with obesity.

VALIDATION

This guideline and its recommendations have been reviewed and approved by the membership, the CPG Committee and the Board of Directors of the CFAS.

SPONSORS

Canadian Fertility & Andrology Society.

RECOMMENDATIONS

Twenty-one evidence based recommendations are provided. These recommendations specifically evaluate the impact of obesity on natural fertility, fertility treatments, and maternal-fetal outcomes. Strategies to lose weight and BMI cut-offs are also addressed.

Gestational Weight Gain and Adverse Birth Outcomes in Twin Pregnancies

OBJECTIVE

To evaluate the association between gestational weight gain in twin pregnancies and small-for-gestational-age (SGA) and large-for-gestational-age (LGA) birth, preterm birth before 32 weeks of gestation, cesarean delivery, and infant death within each prepregnancy body mass index (BMI) category.

METHODS

Data in this population-based study came from Pennsylvania-linked infant birth and death records (2003-2013). We studied 54,836 twins born alive before 39 weeks of gestation. Total pregnancy weight gain (kg) was converted to gestational age-standardized z scores. Multivariable modified Poisson regression models stratified by prepregnancy BMI were used to estimate associations between z scores and outcomes. A probabilistic bias analysis, informed by an internal validation study, evaluated the effect of BMI and weight gain misclassification.

RESULTS

Gestational weight gain z score was negatively associated with SGA and positively associated with LGA and cesarean delivery in all BMI groups. The relation between weight gain and preterm birth was U-shaped in nonobese women. An increased risk of infant death was observed for very low weight gain among normal-weight women and for high weight gain among women without obesity. Most excess risks of these outcomes were observed at weight gains at 37 weeks of gestation that are equivalent to less than 14 kg or more than 27 kg in underweight or normal-weight women, less than 11 kg or more than 28 kg in overweight women, and less than 6.4 kg or more than 26 kg in women with obesity. The bias analysis supported the validity of the conventional analysis.

CONCLUSION

Very low or very high weight gains were associated with the adverse outcomes we studied. If the associations we observed are even partially reflective of causality, targeted modification of pregnancy weight gain in women carrying twins might improve pregnancy outcomes.

Male partners of subfertile couples in which the spouse is obese display adverse weight and lifestyle associated with reduced sperm quality

OBJECTIVES

To assess: 1-the spousal concordance of lifestyle and anthropometric characteristics between partners of infertile couples in which the woman is obese; and 2-in men, the influence of these characteristics on their conventional seminal parameters.

DESIGN

Cross-sectional study.

SETTING

Fertility clinic of the Centre hospitalier universitaire de Sherbrooke, Canada, between January 2012 and February 2015.

PATIENTS

97 infertile heterosexual couples in which women were obese and seeking fertility treatments.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Weight and percentage of fat mass were evaluated using a scale with foot-to-foot bio-impedance. Abdominal obesity was estimated with waist circumference and lifestyle habits, by a self-reported questionnaire. Seminal parameters were analysed and collected according to the WHO guidelines (Kruger's strict criteria for seminal morphology).

RESULTS

There was a significant spousal concordance for the percentage of fat mass, leisure activities and overall nutritional quality. Accordingly, male participants displayed anthropometric and lifestyle characteristics at higher risk than Canadian men of similar age. Moreover, BMI, daily consumption of fruits & vegetables and sleeping hours in men were independently associated to the total motile sperm count.

CONCLUSION

This is the first study to report concordance for anthropometric and lifestyle characteristics between partners of infertile couples in which the woman is obese. These characteristics in men were more adverse than in the general population and were associated with reduced sperm quality. Altogether, our results suggest that male partners of infertile couples could benefit from participating in the lifestyle intervention that is already recommended for their spouse affected by obesity.

CAPSULE

Because partners of subfertile couples in which the woman is obese share adverse anthropometric and lifestyle characteristics, male partners should be implicated in lifestyle interventions already indicated for their spouse.

Implementing a best-practice model of gestational diabetes mellitus care in dietetics: a qualitative study

Background

Translating research into clinical practice is challenging for health services. Emerging approaches in implementation science recognise the need for a theory–driven approach to identify and overcome barriers to guideline adherence. However, many clinicians do not have the capacity, confidence, or expertise to realise change in their local settings. Recently, two regional sites participated in a facilitated implementation project of an evidence-based model of gestational diabetes mellitus (GDM) care in dietetics, supported by a team at a metropolitan centre. This study describes (i) stakeholder experiences’, and (ii) learnings to inform implementation of the model of care (MOC) across Queensland.

Methods

This qualitative descriptive study utilised semi-structured telephone interviews with staff involved in implementation of the MOC project at two regional sites. Eight participants were recruited; five participants were from one site. Interviews were transcribed and analysed to identify recurrent themes.

Results

Four main themes were derived: (1) catalyst for positive change, (2) managing project logistics, (3) overcoming barriers, and (4) achieving change.

Conclusions

A model of external facilitated implementation using an evidence-based decision making tool is an effective method of fostering health service change and is acceptable to staff. Key elements of the facilitation were building confidence and capacity in local implementers, through regular contact, encouraging local networking, linking to higher management support and assessing and/or influencing workplace or organizational culture. However, the balance between delivering clinical care while participating in a service change project proved challenging to many participants.

Diet quality as assessed by the Healthy Food Intake Index and relationship with serum lipoprotein particles and serum fatty acids in pregnant women at increased risk for gestational diabetes

The importance of overall diet in modifying circulating lipoprotein particles and fatty acids during pregnancy is unclear. We examined the relationships of diet quality as assessed by the validated Healthy Food Intake Index (HFII) with serum HDL, LDL and VLDL particle concentrations and sizes and proportions of serum fatty acids in pregnant women at high risk for gestational diabetes mellitus (GDM). Overall, 161 women with a BMI of ≥30 kg/m2 and/or a history of GDM were drawn from the Finnish Gestational Diabetes Prevention Study, which is a dietary and exercise intervention trial to prevent GDM. At baseline, the HFII score was inversely related to concentrations of HDL particles (P=0·010) and MUFA (P=0·010) and positively related to concentrations of n-3 (P<0·001) and n-6 (P=0·003) PUFA. The significance for MUFA disappeared after adjustments. An increase in the HFII score from the first to second trimester of pregnancy correlated with reduced VLDL particle size (r −0·16, 95 % CI −0·31, −0·01), decreased MUFA concentrations (r −0·17, 95 % CI −0·31, −0·01) and elevated n-6 PUFA concentrations (r 0·16, 95 % CI 0·01, 0·31). In the maximum-adjusted model, the results remained significant except for VLDL particle size. These findings suggest that higher diet quality as defined by the HFII is related to a more favourable serum fatty acid profile, whereas the relationship with serum lipoprotein profile is limited in pregnant women at increased GDM risk.

Clinically relevant improvements achieved from a facilitated implementation of a gestational diabetes model of care

AIM

Medical nutrition therapy is a cornerstone treatment in gestational diabetes; however, most Australian women diagnosed with gestational diabetes do not receive this. The project evaluated adaptation of a successful evidence-based gestational diabetes model of care implementation from a tertiary centre into regional sites with varied demographics, population size and service capacity.

METHODS

The project used a hub (project team)-spoke (sites) model in Far North Queensland (Site 1) and regional South-East Queensland (Site 2). Sites selected demonstrated strong gestational diabetes team cohesiveness and project commitment. The project phases were consultation, baseline, transition and implementation. A best practice decision tree tool was provided to assess/manage barriers to the model of care and clinical outcomes captured through a project database.

RESULTS

Role clarification of site members, management engagement, site visits, decision tree and database refinement were completed in the project's first phase. Unexpected organisational and team barriers prevented timeline implementation as planned. Sites negotiated relevant reallocation of resources to achieve project deliverables. The proportion of women seen according to best practice increased from 3.5 to 87.8% (P < 0.001) (Site 1) and nil to 4.8% (P = 0.09) (Site 2), and those on medication dropped by 3.4 (Site 1) and 9.1% (Site 2).

CONCLUSIONS

This project demonstrates a successful implementation using a facilitated and rigorous approach. Support, engagement and tools at many levels were keys to success at both sites. The present study illustrates the opportunities and challenges of conducting implementation research within routine clinical care, particularly in resource-challenged sites.

High-Fat, High-Sugar Diet Disrupts the Preovulatory Hormone Surge and Induces Cystic Ovaries in Cycling Female Rats

Diet-induced obesity has been associated with various metabolic and reproductive disorders, including polycystic ovary syndrome. However, the mechanisms by which obesity influences the reproductive system are still not fully known. Studies have suggested that impairments in hormone signaling are associated with the development of symptoms such as acyclicity and ovarian cysts. However, these studies have often failed to address how these hormonal changes arise and how they might contribute to the progression of reproductive diseases. In the present study, we used a high-fat, high-sugar (HFHS) diet to induce obesity in a female rodent model to determine the changes in critical reproductive hormones that might contribute to the development of irregular estrous cycling and reproductive cycle termination. The HFHS animals exhibited impaired estradiol, progesterone (P4), and luteinizing hormone (LH) surges before ovulation. The HFHS diet also resulted in altered basal levels of testosterone (T) and LH. Furthermore, alterations in the basal P4/T ratio correlated strongly with ovarian cyst formation in HFHS rats. Thus, this model provides a method to assess the underlying etiology of obesity-related reproductive dysfunction and to examine an acyclic reproductive phenotype as it develops.

Patient-Provider Communication and Counseling about Gestational Weight Gain and Physical Activity: A Qualitative Study of the Perceptions and Experiences of Latinas Pregnant with their First Child

Latina women in the United States (U.S.) are disproportionately affected by obesity and are more likely to begin pregnancy overweight and gain excessive weight during pregnancy. The prenatal care period represents a window of opportunity for women to access the healthcare system and receive preventive services, education, nutritional support, and other social services to improve pregnancy outcomes. Excessive gestational weight gain (GWG) has numerous negative short- and long-term consequences for both the mother and newborn. We explored nulliparous Latina women's perceptions about their experiences communicating with their primary healthcare provider about GWG and physical activity (PA) to identify possible intervention targets using in-depth, semi-structured interviews. Bilingual, trained research staff conducted 23 interviews with first-time pregnant Latinas between 22 and 36 weeks of gestation. Interviews were transcribed verbatim and analyzed using content analysis. Salient text passages were extracted, shortened, coded, and grouped into categories. Women, including those who self-identified as being overweight or obese prior to pregnancy, reported receiving limited or no advice from their healthcare providers about GWG or PA. Additionally, analysis revealed that although participants value information received from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program counselors, they would like to receive more information from their primary healthcare providers about adequate GWG. Furthermore, study findings indicate that some participants received conflicting information regarding PA during pregnancy. Study findings suggest the need for increased integration of communication and counseling about GWG and PA into prenatal care services to promote healthy weight gain and PA among low-income Latina women.

Weight resilience and fruit and vegetable intake among African-American women in an obesogenic environment

OBJECTIVE

To investigate relationships between weight resilience (maintaining a normal weight in a food desert environment) and fruit and vegetable (F&V) intake, attitudes and barriers.

DESIGN

Cross-sectional, in-person surveys collected May-December 2011, including self-reported data on F&V-related psychosocial factors, attitudes and barriers. Two 24 h dietary recalls were completed; weight and height were measured. Multivariable regression models estimated prevalence ratios (95 % CI).

SETTING

Two low-income, predominantly African-American food deserts in Pittsburgh, Pennsylvania, USA.

SUBJECTS

Women aged 18-49 years (n 279) who were the primary food shopper in a household randomly selected for a parent study.

RESULTS

Fifteen per cent were weight resilient, 30 % were overweight and 55 % were obese. Overall, 25 % reported eating ≥5 F&V servings/d. After adjustment for age, education, parity, employment, living alone, physical activity, per capita income and mean daily energy intake, women eating ≥5 F&V servings/d were 94 % more likely to be weight resilient compared with those eating <5 servings/d (1·94; 1·10, 3·43). Across BMI groups, self-efficacy regarding F&V consumption was high and few F&V barriers were reported. The most frequently reported barrier was concern about the cost of F&V (36 %). Of the attitudinal F&V-related factors, only concern about wasting food when serving F&V was associated with weight resilience in adjusted models (0·29; 0·09, 0·94). In a model predicting consuming ≥5 F&V servings/d, driving one's own car to the store was the only attitudinal F&V-related factor associated with consumption (1·50; 1·00, 2·24).

CONCLUSIONS

In this population, weight resilience may be encouraged by improving access to affordable and convenient F&V options and providing education on ways to make them palatable to the entire household, rather than by shifting women's F&V perceptions, which are already positive.

Improving pregnancy outcome in obese women: the UK Pregnancies Better Eating and Activity randomised controlled Trial

Background

Obesity in pregnancy is associated with insulin resistance, which underpins many common complications including gestational diabetes mellitus (GDM) and fetal macrosomia.

Objectives

To assess the effect of a complex behavioural intervention based on diet and physical activity (PA) on the risk of GDM and delivery of a large-for-gestational age (LGA) infant.

Design

Three phases: (1) the development phase, (2) the pilot study and (3) a multicentre randomised controlled trial (RCT) comparing a behavioural intervention to improve glycaemic control with standard antenatal care in obese pregnant women. A cost–utility analysis was undertaken to estimate the cost-effectiveness of the health training (intervention) over and above standard care (control).

Setting

Pilot study: antenatal clinics in four inner-city UK hospitals. RCT: eight antenatal clinics in eight UK inner-city hospitals.

Participants

Women were eligible for inclusion if they had a body mass index of ≥ 30 kg/m2, were pregnant with a single fetus and at 15+0to 18+6weeks’ gestation, were able to give written informed consent and were without predefined disorders.

Intervention

The intervention comprised an initial session with a health trainer, followed by eight weekly sessions. Dietary advice recommended foods with a low dietary glycaemic index, avoidance of sugar-sweetened beverages and reduced saturated fats. Women were encouraged to increase daily PA.

Main outcome measures

Development phase: intervention development, acceptability and optimal approach for delivery. Pilot study: change in dietary and PA behaviours at 28 weeks’ gestation. RCT: the primary outcome of the RCT was, for the mother, GDM [as measured by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)’s diagnostic criteria] and, for the infant, LGA delivery (i.e. customised birthweight ≥ 90th centile for gestational age).

Results

Development phase: following a literature meta-analysis, a study of dietary intention questionnaires and semistructured interviews, an intervention based on behavioural science was developed that incorporated optimal and acceptable methods for delivery. Pilot study: the pilot study demonstrated improvement in dietary behaviours in the intervention compared with the standard care arm but no increase in objectively measured PA. Process evaluation demonstrated feasibility and general acceptability. RCT: the RCT showed no effect of the intervention on GDM in obese pregnant women or the number of deliveries of LGA infants. There was a reduction in dietary glycaemic load (GL) and reduced saturated fat intake, an increase in PA and a modest reduction in gestational weight gain, all secondary outcomes. Lower than expected was the number of LGA infant deliveries in all women, which suggested that universal screening for GDM with IADPSG’s diagnostic criteria, and subsequent treatment, may reduce the number of deliveries of LGA infants. According to the cost–utility analysis, the estimated probability that the UK Pregnancies Better Eating and Activity Trial (UPBEAT) behavioural intervention is cost-effective at the £30,000/quality-adjusted life-year willingness-to-pay threshold was 1%.

Limitations

Included the high refusal rate for participation and self-reported assessment of diet and PA.

Conclusions

The UPBEAT intervention, an intense theoretically based intervention in obese pregnant women, did not reduce the risk of GDM in women or the number of LGA infant deliveries, despite successfully reducing the dietary GL. Based on total cost to the NHS provider and health gains, the UPBEAT intervention provided no supporting evidence to suggest that the intervention represents value for money based on the National Institute for Health and Care Excellence benchmarks for cost-effectiveness.

Future work

Alternative strategies for reducing the risk of GDM in obese pregnant women and the number of LGA infant deliveries should be considered, including development of clinically effective interventions to prevent obesity in women of reproductive age, of clinically effective interventions to reduce weight retention following pregnancy and of risk stratification tools in early pregnancy.

Trial registration

Current Controlled Trials ISRCTN89971375 and UK Clinical Research Network Portfolio 5035.

Funding

This project was funded by the NIHR Programme Grant for Applied Research programme and will be published in full inProgramme Grants for Applied Research, Vol. 5, No. 10. See the NIHR journals library website for further project information. Contributions to funding were also provided by the Chief Scientist Office CZB/4/680, Scottish Government Health Directorates, Edinburgh; Guys and St Thomas’ Charity, Tommy’s Charity (Lucilla Poston, Annette L Briley, Paul T Seed) and the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK and the Academy of Finland, Finland. Keith M Godfrey was supported by the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre. Lucilla Poston and Keith M Godfrey were supported by the European Union’s Seventh Framework Programme (FP7/2007-2013), project EarlyNutrition under grant agreement number 289346.

Retrospective analysis of age-adjusted body mass index among pre-pregnant women in the Lithuanian urban area during three decades

BACKGROUND

The prevalence of maternal obesity at the beginning of pregnancy is increasing. However, there are some studies reporting the stabilisation of obesity epidemic or even the downward trend in the general population.

OBJECTIVE

To determine the prevalence of overweight and obesity in Lithuanian pre-pregnant women during 3 decades.

METHODS

This observational retrospective study included a sample of 2827, women aged 18-44 years who gave birth in 1987-1989, 1996-1997 and 2007-2010: 861 (30.5%), 995 (35.2%) and 971 (34.3%), respectively. All women were divided into groups by body mass index (BMI) calculated from self-reported weight and height, and age reported during the first antenatal visit. Quantitative parametric variables were expressed as mean and SD; qualitative variables, as absolute numbers (n) and percentage (%). For parametric data, analysis of variance (ANOVA) was used. Differences were considered statistically significant at p<0.05.

RESULTS

The prevalence of overweight and obesity among women aged 18-24 years decreased from 20.9% in 1987-1989 to 9.5% in 1996-1997 but increased to 15.7% in 2007-2010; among women aged 25-34 years, decreased from 35.5% in 1987-1989 to 23% in 1996-1997 and to 22.4% in 2007-2010; and among women aged 35-44 years decreased from 64.9% in 1987-1989 to 34% in 1996-1997 but increased to 45.3% in 2007-2010. BMI increased with an increasing age (r=0.254, p<0.05). Analysis by separate periods (1987-1989, 1996-1997 and 2007-2010) revealed a positive correlation between BMI and age at the first antenatal visit in all periods (r=0.325, p<0.01; r=0.266, p<0.01; and r=0.210, p<0.01, respectively).

CONCLUSIONS

The prevalence of overweight and obesity among pre-pregnant women tended to decrease in the Lithuanian urban area during 3 decades. A slight increase in overweight and obesity documented in 2007-2010 compared with 1996-1997 most likely was caused by older maternal age.

Diet, Pre-pregnancy BMI, and Gestational Weight Gain in Puerto Rican Women

OBJECTIVES

To describe the dietary patterns in pregnant woman and determine the association between diet factors, pre-pregnancy Body Mass Index (BMI) and socio-demographic characteristics with gestational weight gain (GWG).

METHODS

This is a secondary analysis of a longitudinal cohort study of pregnant women exploring the risk factors for preterm birth, the Puerto Rico Testsite for Exploring Contamination Threats program. Recruitment was conducted during 2011-2014. Data was collected from multiple sources. GWG was calculated using maternal weight recorded in the medical records at the first and last prenatal visits and classified according to the Institute of Medicine guidelines. Sociodemographic characteristics were obtained at baseline using an interviewed-based questionnaire. Participants completed a self-administered food frequency questionnaire at 20-28 weeks to assess dietary patterns. Analysis of associations between variables was conducted using Chi Square tests.

RESULTS

A total of 160 women with term pregnancies were included in this analysis. Mean pre-pregnancy BMI was 25.4 ± 5.48 kg/m(2), with 44.4 % classified as overweight/obese. Excessive GWG was observed in 24.4 % of the participants. Socio-demographic characteristics were not associated with GWG. Being overweight/obese at the start of pregnancy was significantly associated with excessive GWG (p < 0.05). In addition, women consuming one or more fruit drinks per day were more likely to have an excessive GWG while those consuming less than one fruit drink per day were more likely to have an adequate GWG (p < 0.05).

CONCLUSIONS FOR PRACTICE

Being obese before pregnancy and frequently consuming fruit drinks were important determinants of excessive GWG in this group.

Educational intervention regarding diet and physical activity for pregnant women: changes in knowledge and practices among health professionals

BACKGROUND

The knowledge and practices of health professionals have a recognized role in behaviors related to the health of their patients. During pregnancy, this influence can be even stronger because there is frequent contact between women and doctors/nurses at periodic antenatal visits. When trained, supported and motivated, these professionals can act as health promoters. This study aimed to evaluate the effect of a focused educational intervention on improving the knowledge and practices of health professionals concerning diet and physical activity during pregnancy.

METHODS

A controlled, non-randomized study was performed to assess the effects of an educational intervention on the knowledge and practices of nurses and doctors who provide primary care to pregnant women. The intervention group, doctors and nurses (n = 22) from the family health units in a medium-sized city of São Paulo State, Brazil, received 16 h of training comprising an introductory course and three workshops, whereas the control group, doctors and nurses (n = 20) from traditional basic health units in Botucatu, did not. The professionals' knowledge was assessed at two time points, 1 month prior to and 1 year after the beginning of the intervention, using an ad hoc self-report questionnaire. The increases in the knowledge scores for walking and healthy eating of the intervention and control groups were calculated and compared using Student's t-test. To analyze the professionals' practice, women in the second trimester of pregnancy were asked whether they received guidance on healthy eating and leisure-time walking; 140 of these women were cared for by professionals in the intervention group, and 141 were cared for by professionals in the control group. The percentage of pregnant women in each group that received guidance was compared using the chi-square test and the Prevalence Ratio (PR), and the corresponding 95 % confidence intervals (CI) were calculated.

RESULTS

The intervention improved the professionals' knowledge regarding leisure-time walking (92 % increase in the score, p < 0.001). The women who were cared for by the intervention group were more likely to receive guidance regarding leisure-time walking (PR = 2.65; 95 % CI = 1.82-3.83) and healthy eating (PR = 1.76; 95 % CI = 1.34-2.31) when compared to the control group.

CONCLUSION

It is possible to improve the knowledge and practices of health professionals through the proposed intervention aimed at primary health care teams providing antenatal care.

Neighborhood-Level Poverty at Menarche and Prepregnancy Obesity in African-American Women

Introduction. Menarche is a critical time point in a woman's reproductive system development; exposures at menarche may influence maternal health. Living in a poorer neighborhood is associated with adult obesity; however, little is known if neighborhood factors at menarche are associated with prepregnancy obesity. Methods. We examined the association of neighborhood-level poverty at menarche with prepregnancy body mass index category in 144 pregnant African-American women. Address at menarche was geocoded to census tract (closest to year of menarche); neighborhood-level poverty was defined as the proportion of residents living under the federal poverty level. Cumulative logistic regression was used to examine the association of neighborhood-level poverty at menarche, in quartiles, with categorical prepregnancy BMI. Results. Before pregnancy, 59 (41%) women were obese. Compared to women in the lowest neighborhood-level poverty quartile, women in the highest quartile had 2.9 [1.2, 6.9] times higher odds of prepregnancy obesity; this was slightly attenuated after adjusting for age, marital status, education, and parity (odds ratio: 2.3 [0.9, 6.3]). Conclusions. Living in a higher poverty neighborhood at menarche is associated with prepregnancy obesity in African-American women. Future studies are needed to better understand the role of exposures in menarche on health in pregnancy.

The Role of Avocados in Maternal Diets during the Periconceptional Period, Pregnancy, and Lactation

Maternal nutrition plays a crucial role in influencing fertility, fetal development, birth outcomes, and breast milk composition. During the critical window of time from conception through the initiation of complementary feeding, the nutrition of the mother is the nutrition of the offspring—and a mother’s dietary choices can affect both the early health status and lifelong disease risk of the offspring. Most health expert recommendations and government-sponsored dietary guidelines agree that a healthy diet for children and adults (including those who are pregnant and/or lactating) should include an abundance of nutrient-rich foods such as fruits and vegetables. These foods should contain a variety of essential nutrients as well as other compounds that are associated with lower disease risk such as fiber and bioactives. However, the number and amounts of nutrients varies considerably among fruits and vegetables, and not all fruit and vegetable options are considered “nutrient-rich”. Avocados are unique among fruits and vegetables in that, by weight, they contain much higher amounts of the key nutrients folate and potassium, which are normally under-consumed in maternal diets. Avocados also contain higher amounts of several non-essential compounds, such as fiber, monounsaturated fats, and lipid-soluble antioxidants, which have all been linked to improvements in maternal health, birth outcomes and/or breast milk quality. The objective of this report is to review the evidence that avocados may be a unique nutrition source for pregnant and lactating women and, thus, should be considered for inclusion in future dietary recommendations for expecting and new mothers.

Low Gestational Weight Gain in Obese Women and Pregnancy Outcomes

Obesity during pregnancy and excessive weight gain during this period are associated with several maternal-fetal and neonatal complications. Moreover, a significant percentage of women have weight retention in the postpartum period, especially those with excessive weight gain during pregnancy. The recommendations of the 2009 Institute of Medicine were based on observational studies that have consistently shown that women with weight gain within the recommended range had better outcomes during pregnancy. In patients with obesity, however, there is no recommendation for weight gain, according to the class of obesity. This review, therefore, aims to evaluate the evidence on key maternal and fetal complications related to low weight gain during pregnancy in obese and overweight patients.

Maternal dietary intake and physical activity habits during the postpartum period: associations with clinician advice in a sample of Australian first time mothers

BACKGROUND

Numerous health benefits are associated with achieving optimal diet and physical activity behaviours during and after pregnancy. Understanding predictors of these behaviours is an important public health consideration, yet little is known regarding associations between clinician advice and diet and physical activity behaviours in postpartum women. The aims of this study were to compare the frequency of dietary and physical activity advice provided by clinicians during and after pregnancy and assess if this advice is associated with postpartum diet and physical activity behaviours.

METHODS

First time mothers (n = 448) enrolled in the Melbourne InFANT Extend trial completed the Cancer Council of Australia's Food Frequency Questionnaire when they were three to four months postpartum, which assessed usual fruit and vegetable intake (serves/day). Total physical activity time, time spent walking and time in both moderate and vigorous activity for the previous week (min/week) were assessed using the Active Australia Survey. Advice received during and following pregnancy were assessed by separate survey items, which asked whether a healthcare practitioner had discussed eating a healthy diet and being physically active. Linear and logistic regression assessed associations of advice with dietary intake and physical activity.

RESULTS

In total, 8.6% of women met guidelines for combined fruit and vegetable intake. Overall, mean total physical activity time was 350.9 ± 281.1 min/week. Time spent walking (251.97 ± 196.78 min/week), was greater than time spent in moderate (36.68 ± 88.58 min/week) or vigorous activity (61.74 ± 109.96 min/week) and 63.2% of women were meeting physical activity recommendations. The majority of women reported they received advice regarding healthy eating (87.1%) and physical activity (82.8%) during pregnancy. Fewer women reported receiving healthy eating (47.5%) and physical activity (51.9%) advice by three months postpartum. There was no significant association found between provision of dietary and/or physical activity advice, and mother's dietary intakes or physical activity levels.

CONCLUSIONS

Healthy diet and physical activity advice was received less after pregnancy than during pregnancy yet no association between receipt of advice and behaviour was observed. More intensive approaches than provision of advice may be required to promote healthy diet and physical activity behaviours in new mothers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12611000386932 13/04/2011).

The Obesity-Fertility Protocol: a randomized controlled trial assessing clinical outcomes and costs of a transferable interdisciplinary lifestyle intervention, before and during pregnancy, in obese infertile women

BACKGROUND

Obesity in infertile women increases the costs of fertility treatments, reduces their effectiveness and increases significantly the risks of many complications of pregnancy and for the newborn. Studies suggest that even a modest loss of 5-10 % of body weight can restore ovulation. However, there are gaps in knowledge regarding the benefits and cost-effectiveness of a lifestyle modification program targeting obese infertile women and integrated into the fertility clinics. This study will evaluate clinical outcomes and costs of a transferable interdisciplinary lifestyle intervention, before and during pregnancy, in obese infertile women. We hypothesize that the intervention will: 1) improve fertility, efficacy of fertility treatments, and health of mothers and their children; and 2) reduce the cost per live birth, including costs of fertility treatments and pregnancy outcomes.

METHODS/DESIGN

Obese infertile women (age: 18-40 years; BMI ≥30 kg/m(2) or ≥27 kg/m(2) with polycystic ovary syndrome) will be randomised to either a lifestyle intervention followed by standard fertility treatments after 6 months if no conception has been achieved (intervention group) or standard fertility treatments only (control group). The intervention and/or follow-up will last for a maximum of 18 months or up to the end of pregnancy. Evaluation visits will be planned every 6 months where different outcome measures will be assessed. The primary outcome will be live-birth rates at 18 months. The secondary outcomes will be sub-divided into four categories: lifestyle and anthropometric, fertility, pregnancy complications, and neonatal outcomes. Outcomes and costs will be also compared to similar women seen in three fertility clinics across Canada. Qualitative data will also be collected from both professionals and obese infertile women.

DISCUSSION

This study will generate new knowledge about the implementation, impacts and costs of a lifestyle management program in obese infertile women. This information will be relevant for decision-makers and health care professionals, and should be generalizable to North American fertility clinics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01483612. Registered 25 November 2011.

Pandemic of Pregnant Obese Women: Is It Time to Re-Evaluate Antenatal Weight Loss?

The Obesity pandemic will afflict future generations without successful prevention, intervention and management. Attention to reducing obesity before, during and after pregnancy is essential for mothers and their offspring. Preconception weight loss is difficult given that many pregnancies are unplanned. Interventions aimed at limiting gestational weight gain have produced minimal maternal and infant outcomes. Therefore, increased research to develop evidence-based clinical practice is needed to adequately care for obese pregnant women especially during antenatal care. This review evaluates the current evidence of obesity interventions during pregnancy various including weight loss for safety and efficacy. Recommendations are provided with the end goal being a healthy pregnancy, optimal condition for breastfeeding and prevent the progression of obesity in future generations.

Understanding and Improving Cardiovascular Health: An Update on the American Heart Association's Concept of Cardiovascular Health

The American Heart Association's 2020 Strategic Impact Goal is "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%." To monitor progress towards this goal, a new construct "ideal cardiovascular health" (iCVH) was defined that includes the simultaneous presence of optimal levels of seven health behaviors (physical activity, smoking, dietary intake, and body mass index) and factors (total cholesterol, blood pressure and fasting blood glucose). In this review, we present a summary of major concepts related to the concept of iCVH and an update of the literature in this area since publication of the 2020 Strategic Impact Goal, including trends in iCVH prevalence, new determinants and outcomes related to iCVH, strategies for maintaining or improving iCVH, policy implications of the iCVH model, and the remaining challenges to reaching the 2020 Strategic Impact Goal.

Call to action: continuum of care for females of reproductive age to prevent obesity and ensure better health outcomes of offspring through nutrition

The health and nutritional status of women of reproductive age has tremendous impact on the health of future populations; therefore, special attention should be paid to promoting women's health, especially a healthy weight at this critical time period. The purpose of the paper is to provide information on the nutritional needs of women at various stages of the reproductive age spectrum, including preconception/interconception and during pregnancy to achieve and maintain a healthy weight. The Socio-Ecological Model (SEM) is presented to help practitioners understand the importance of intervening where women of reproductive age live, work, and frequent.

Maternal body size prior to pregnancy, gestational diabetes and weight gain: associations with insulin resistance in children at 9-10 years

AIMS

To investigate whether maternal body size pre-pregnancy, gestational diabetes and weight gain are independently associated with subsequent insulin resistance in children; and to examine the potential mediating role of child's body size in any associations.

METHODS

At 9-10 years, 443 children took part in a follow-up of a prospective cohort. Of those, 163 children elected to provide a fasting blood sample and child insulin resistance was estimated by homeostasis model assessment. Generalized linear models with log link function and Gaussian family were used to assess associations with antenatal exposures. Potential confounders were considered as well as the role of the child's size.

RESULTS

Prior to pregnancy, 23% of mothers were overweight and another 17% obese. All women were screened for gestational diabetes, with 6% diagnosed. On average, women gained an estimated 14 kg during pregnancy. Gestational diabetes was positively associated with child insulin resistance. In addition, maternal pre-pregnancy body mass index (BMI) was associated with child insulin resistance in a non-linear manner: a positive, progressive association was observed until BMI of 30 kg/m² was reached, but not thereafter. Estimated gestational weight gain was not associated with child insulin resistance. These findings were not accounted for by size of the child at birth or at 9-10 years.

CONCLUSIONS

Maternal body size prior to pregnancy is positively associated with increases in child insulin resistance, at least until the 'obese' category is reached. This is independent of gestational diabetes and not mediated by body size of the child, suggesting genetic and/or developmental programming origins.

Pickles and ice cream! Food cravings in pregnancy: hypotheses, preliminary evidence, and directions for future research

Women in the United States experience an increase in food cravings at two specific times during their life, (1) perimenstrually and (2) prenatally. The prevalence of excess gestational weight gain (GWG) is a growing concern due to its association with adverse health outcomes in both mothers and children. To the extent that prenatal food cravings may be a determinant of energy intake in pregnancy, a better understanding of craving etiology could be crucial in addressing the issue of excessive GWG. This paper reviews the available literature to corroborate and/or dispute some of the most commonly accepted hypotheses regarding the causes of food cravings during pregnancy, including a role of (1) hormonal changes, (2) nutritional deficits, (3) pharmacologically active ingredients in the desired foods, and (4) cultural and psychosocial factors. An existing model of perimenstrual chocolate craving etiology serves to structure the discussion of these hypotheses. The main hypotheses discussed receive little support, with the notable exception of a postulated role of cultural and psychosocial factors. The presence of cravings during pregnancy is a common phenomenon across different cultures, but the types of foods desired and the adverse impact of cravings on health may be culture-specific. Various psychosocial factors appear to correlate with excess GWG, including the presence of restrained eating. Findings strongly suggest that more research be conducted in this area. We propose that future investigations fall into one of the four following categories: (1) validation of food craving and eating-related measures specifically in pregnant populations, (2) use of ecological momentary assessment to obtain real time data on cravings during pregnancy, (3) implementation of longitudinal studies to address causality between eating disorder symptoms, food cravings, and GWG, and (4) development of interventions to ensure proper prenatal nutrition and prevent excess GWG.

The performance of various anthropometric assessment methods for predicting low birth weight in adolescent pregnant women

Objective: To evaluate the performance of various anthropometric evaluation methods for adolescent pregnant women in the prediction of birth weight. Methods: It is a cross-sectional study including 826 adolescent pregnant women. In the pre-pregnancy body mass index (BMI) classification, the recommendations of the World Health Organization were compared with that of the Brazilian Ministry of Health and the Institute of Medicine (IOM) of 1992 and 2006. The gestational weight gain adequacy was evaluated according to the classification of IOM of 1992, of 2006 and of the Brazilian Ministry of Health. The newborns were classified as low birth weight (LBW) or macrosomic. Multinomial logistic regression was used for statistical analysis and sensibility, specificity, accuracy, positive and negative predictive values were calculated. Results: The evaluation, according to the Brazilian Ministry of Health, showed the best prediction for LBW among pregnant women with low weight gain (specificity = 69.5%). The evaluation according to the IOM of 1992 showed the best prediction for macrosomia among pregnant women with high weight gain (specificity = 50.0%). The adequacy of weight gain according to the IOM of 1992 classification showed the best prediction for LBW (OR = 3.84; 95%CI 2.19 - 6.74), followed by the method of the Brazilian Ministry of Health (OR = 2.88, 95%CI 1.73 - 4.79), among pregnant women with low weight gain. Conclusion: It is recommended the adoption of the Brazilian Ministry of Health proposal, associated with BMI cut-offs specific for adolescents as an anthropometric assessment method for adolescent pregnant women.

Gestational weight gain recommendations in the context of the obesity epidemic

The impact of the obesity epidemic on women of childbearing age has been of particular concern in recent years as a result of studies linking maternal weight status to long-term adverse outcomes for obese mothers and their offspring. The US Institute of Medicine developed new gestational weight gain guidelines based on this literature that attempts to strike a balance between the known risks and benefits of weight gain during pregnancy. More studies that include large numbers of obese women, examine outcomes beyond the perinatal period, and identify safe and effective pregnancy weight gain interventions are needed before lower weight gain recommendations can be made for obese women.

Nutrition education for postpartum women: a pilot study

This pilot study examined the effectiveness of a 4-month clinic-based dietary intervention emphasizing the intake of deep yellow and dark green vegetables versus usual care on improving diet quality in postpartum women. The intervention group (n = 31) received 1 face-to-face nutrition education session with a registered dietitian, 2 follow-up phone calls, and 3 pamphlets distributed by mail. The usual care group (n = 25) received handouts with guidelines on healthy eating. Dietary outcomes were assessed from 3-day food recalls and evaluated using paired and independent t tests. Intervention women exhibited a significant increase in total vegetable intake (P < .001) and in dark green and deep yellow vegetables (P < .001). In comparison, the control group increased the intake of total vegetables (P < .001), but did not increase the consumption of dark green and deep yellow vegetables. When comparing the change in intake between study groups for both types of vegetables, the difference was not significant. Furthermore, 61% of the intervention women met the goals for total vegetable intake compared with 12% for the usual care group (P < .001). The intervention group also had a greater percentage of women (25.8%) that met the goal for deep yellow and dark green vegetable intake when compared with the usual care group (8%; P < .08). These results suggest that postpartum women are receptive to nutrition education and that nutrition education can influence vegetable intake.

Gestational weight gain in twin pregnancies and maternal and child health: a systematic review

Our objective was to systematically review the data interrogating the association between gestational weight gain (GWG) and maternal and child health among women with twin gestations. We identified 15 articles of twin gestations that studied GWG in relation to a maternal, perinatal or child health outcome and controlled for gestational age at delivery and prepregnancy body mass index. A positive association between GWG and fetal size was consistently found. Evidence on preterm birth and pregnancy complications was inconsistent. The existing studies suffer from serious methodological weaknesses, including not properly accounting for the strong correlation between gestational duration and GWG and not controlling for chorionicity. In addition, serious perinatal outcomes were not studied, and no research is available on the association between GWG and outcomes beyond birth. Our systematic review underscores that GWG in twin gestations is a neglected area of research. Rigorous studies are needed to inform future evidence-based guidelines.

The effects of mindfulness eating and yoga exercise on blood sugar levels of pregnant women with gestational diabetes mellitus

AIM

This randomized controlled trial was carried out to investigate the effect of mindfulness eating and yoga exercise on blood sugar levels among pregnant Thai women with GDM.

BACKGROUND

Interventions promoting achievement of good glycemic control result in desired pregnancy outcomes. Little is known about the health benefits of mindfulness eating and yoga exercise on blood sugar levels among pregnant with GDM.

METHODS

A randomized controlled trial was carried out. Main outcome measures were capillary fasting plasma glucose, 2-h postprandial blood glucose, and hemoglobin A1c.

RESULTS

The intervention group showed significantly reduced fasting plasma glucose, 2-h postprandial blood glucose, and glycosylated hemoglobin (HbA1c) in the intervention group (p<0.05).

CONCLUSIONS

Mindfulness eating and yoga exercise had health benefits on glycemic control in pregnant women with GDM. It should be recommended in clinical and community health services.

Gestational weight gain and risk of infant death in the United States

OBJECTIVES

We examined the association of prepregnancy body mass index (BMI) and gestational weight gain (GWG) with risk of death during infancy using the Institute of Medicine's (IOM's) Pregnancy Weight Gain Guidelines.

METHODS

We obtained maternal and infant data for 2004-2008 from 159,244 women with a singleton, full-term, live birth in the 41 states that participated in phase 5 of the Pregnancy Risk Assessment Monitoring System. We fit logistic regression models to estimate the association between prepregnancy BMI, GWG, and risk of death during infancy, controlling for confounders.

RESULTS

Only 34% of women gained the IOM-recommended amount of weight during pregnancy. Infants born to underweight, normal-weight, and overweight women with inadequate GWG had odds of mortality during infancy that were 6.18, 1.47, and 2.11 times higher, respectively, than those of infants born to women with adequate GWG. Infants born to obese women with excessive weight gain had a 49% decreased likelihood of mortality.

CONCLUSIONS

A significant association exists between inadequate GWG and infant death that weakens with increasing prepregnancy BMI; weight gain beyond the recommended amount appears to be protective against infant mortality.

Knowledge of obesity and its impact on reproductive health outcomes among urban women

This prospective survey study assessed the knowledge of reproductive outcomes that are affected by obesity among women in an urban community. A total of 207 women attending a community fair on the south side of Chicago participated in the study. A survey assessing knowledge of BMI and of the effects of obesity on general, cardiometabolic and reproductive health outcomes was administered. Subjects ranged in age from 18 to 70 years (mean ± SD, 48.6 ± 12.9 years) and ranged in BMI from 17.3 to 52.1 kg/m(2) (mean ± SD, 31.2 ± 6.7 kg/m(2)). The following percentages of women were aware that obesity increases the risk of miscarriage (37.5 %), irregular periods (35.8 %), infertility (33.9 %), cesarean section (30.8 %), breast cancer (28.0 %), birth defects (23.7 %), stillbirth (14.1 %), and endometrial cancer (18.1 %). This study found that while women in an urban community are aware of the cardiometabolic risks associated with obesity, they demonstrate limited knowledge of the effects of obesity on reproductive outcomes. Public education is needed to increase knowledge and awareness of the reproductive consequences of obesity. Women of reproductive age may be uniquely responsive to obesity education and weight loss intervention.

Maternal overweight and obesity: a survey of clinicians' characteristics and attitudes, and their responses to their pregnant clients

Background

Statewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. Our aim was to assess staff knowledge about, adherence to, and characteristics that influence delivery of care according to these Guidelines.

Methods

An online survey, available over a three week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff working in a tertiary maternity hospital. Outcomes included knowledge of guideline content, advice given, knowledge of obesity pregnancy-related complications, previous training, referral patterns, and staff characteristics, including lifestyle habits, body satisfaction, and Body Mass Index (BMI).

Results

Seventy-three staff completed surveys (59.6% response rate). Mean self-reported BMI was 24.2 ± 4.1 kg/m² (17.9-36.4); 28.5% of staff were overweight (19%) or obese (9.5%), and 27.4% were underweight. However, 28.6%, 2.4%, and 1.2% ‘self-classified’ themselves as overweight, obese, and underweight, respectively. Almost 40% were dissatisfied/extremely dissatisfied with their weight. While the majority reported overweight/obesity (ow/ob) as an important/very important general obstetric issue and most correctly identified associated perinatal complications, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. A quarter indicated they did not provide women with gestational weight gain (GWG) advice relative to BMI category. Staff identified they would like more training in the area of supporting women to achieve and understand the need for healthy GWG. Staff role was significantly associated with guideline adherence (p=0.03) and association with BMI category approached significance (p=0.07). An association was observed between staff’s BMI and their belief in the influence of their advice on women’s GWG (p=0.013) and weight satisfaction and belief in women having the resources to make the changes they recommend (p=0.003).

Conclusions

Whilst lack of guideline knowledge provides a barrier to best-practice care, our findings suggest an interplay between staff confidence and personal characteristics in delivering such care which deserves recognition in staff education and training, and service development programs and future research.

Methodology for adding glycemic index to the National Health and Nutrition Examination Survey nutrient database

Generating valid estimates of dietary glycemic index (GI) and glycemic load (GL) has been a challenge in nutritional epidemiology. The methodologic issues may have contributed to the wide variation of GI/GL associations with health outcomes observed in existing literature. We describe a standardized methodology for assigning GI values to items in the National Health and Nutrition Examination Survey (NHANES) nutrient database using the new International Tables to develop research-driven, systematic procedures and strategies to estimate dietary GI/GL exposures of a nationally representative population sample. Nutrient databases for NHANES 2003-2006 contain information on 3,155 unique foods derived from the US Department of Agriculture National Nutrient Database for Standard Reference versions 18 and 20. Assignment of GI values were made to a subset of 2,078 carbohydrate-containing foods using systematic food item matching procedures applied to 2008 international GI tables and online data sources. Matching protocols indicated that 45.4% of foods had identical matches with existing data sources, 31.9% had similar matches, 2.5% derived GI values calculated with the formula for combination foods, 13.6% were assigned a default GI value based on low carbohydrate content, and 6.7% of GI values were based on data extrapolation. Most GI values were derived from international sources; 36.1% were from North American product information. To confirm data assignments, dietary GI and GL intakes of the NHANES 2003-2006 adult participants were estimated from two 24-hour recalls and compared with published studies. Among the 3,689 men and 4,112 women studied, mean dietary GI was 56.2 (men 56.9, women 55.5), mean dietary GL was 138.1 (men 162.1, women 116.4); the distribution of dietary GI was approximately normal. Estimates of population GI and GL compare favorably with other published literature. This methodology of adding GI values to an existing population nutrient database utilized systematic matching protocols and the latest comprehensive data sources on food composition. The database can be applied in clinical and survey research settings where there is interest in estimating individual and population dietary exposures and relating them to health outcomes.

A systematic review investigating healthy lifestyle interventions incorporating goal setting strategies for preventing excess gestational weight gain

BACKGROUND

Excess gestational weight gain (GWG) is an important risk factor for long term obesity in women. However, current interventions aimed at preventing excess GWG appear to have a limited effect. Several studies have highlighted the importance of linking theory with empirical evidence for producing effective interventions for behaviour change. Theorists have demonstrated that goals can be an important source of human motivation and goal setting has shown promise in promoting diet and physical activity behaviour change within non-pregnant individuals. The use of goal setting as a behaviour change strategy has been systematically evaluated within overweight and obese individuals, yet its use within pregnancy has not yet been systematically explored.

AIM OF REVIEW

To explore the use of goal setting within healthy lifestyle interventions for the prevention of excess GWG.

DATA COLLECTION AND ANALYSIS

Searches were conducted in seven databases alongside hand searching of relevant journals and citation tracking. Studies were included if interventions used goal setting alongside modification of diet and/or physical activity with an aim to prevent excess GWG. The PRISMA guidelines were followed and a two-stage methodological approach was used. Stage one focused on systematically evaluating the methodological quality of included interventions. The second stage assessed intervention integrity and the implementation of key goal setting components.

FINDINGS

From a total of 839 citations, 54 full-text articles were assessed for eligibility and 5 studies met the inclusion criteria. Among interventions reporting positive results a combination of individualised diet and physical activity goals, self-monitoring and performance feedback indicators were described as active components.

CONCLUSION

Interventions based on goal setting appear to be useful for helping women achieve optimal weight gain during pregnancy. However, overweight and obese women may require more theoretically-designed interventions. Further high quality, theoretically-designed interventions are required to determine the most effective and replicable components for optimal GWG.