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

Precision Interventions Targeting the Maternal Metabolic Milieu for Healthy Pregnancies in Obesity

PURPOSE OF REVIEW

Entering pregnancy with obesity increases the risk of adverse health outcomes for parent and child. As such, research interventions are largely focused on limiting excess gestational weight gain during pregnancy, especially in those with obesity. Yet, while many lifestyle interventions are successful in reducing GWG, few affect pregnancy outcomes. Here we review work targeting the metabolic milieu instead of focusing solely on weight.

RECENT FINDINGS

Work done in non-pregnant populations suggests that specifically targeting glucose, triglyceride, and leptin levels or inflammatory makers improves the metabolic milieu and overall health. We posit that precision interventions that include strategies such as time restricted eating, following the 24 h movement guidelines, or reducing sedentary behavior during pregnancy can be successful approaches benefiting the maternal metabolic milieu and minimize the risk of adverse pregnancy outcomes. Personalized tools such as continuous glucose monitors or community-based approaches play an important role in pre-conception health and should be extrapolated to pregnancy interventions to directly benefit the metabolic milieu optimizing health outcomes for both parent and child.

Assessing Moroccan physician knowledge and practices regarding maternal obesity's impact on childhood obesity: Implications for prevention and intervention

BACKGROUND

Childhood obesity is a growing global concern with far-reaching health implications. This study focuses on evaluating the knowledge and practices of physicians in Morocco regarding the link between maternal obesity and childhood obesity. Despite the increasing prevalence of childhood obesity worldwide, this issue remains inadequately addressed in the Moroccan context.

AIM

To assess the awareness and practices of physicians in Morocco concerning the connection between maternal obesity and childhood obesity.

METHODS

The research encompasses a comprehensive survey of practicing physicians, revealing significant gaps in awareness and practices related to maternal obesity.

RESULTS

Notably, a significant portion of doctors do not provide adequate guidance to overweight pregnant women, highlighting the urgency for targeted educational programs.

CONCLUSION

In conclusion, this research illuminates critical areas for improvement in tackling childhood obesity in Morocco. By addressing these gaps, fostering awareness, and enhancing medical practices, the healthcare system can contribute significantly to preventing childhood obesity and improving the overall health of future generations.

Comparison of home exercise under supervision and self home exercise in pregnant women with gestational diabetes: randomized controlled trial

OBJECTIVE

Exercise programs at home are successful in treating gestational diabetes by controlling blood glucose. The aim is to compare the efficacy of the self-directed home exercise program, the standard care alone and the supervised home exercise program in pregnant women with gestational diabetes on blood glucose, quality of life and pregnancy outcomes.

METHODS

This randomized, parallel, single-blind study included 45 pregnant women who were 24-28 weeks of gestation. Participants were randomly divided into the supervised home exercise group (SHEG), home exercise group (HEG) and control group (CG). While the home exercises program was taught and controlled by a physiotherapist in SHEG, the home exercise brochure was given without any training by the gynecologist in HEG. Control group maintained their usual daily care. The home exercise intervention included low to moderate structured exercise performed three days per week for 8 weeks. Their glucose responses, quality of life and pregnancy outcomes were assessed pre- and post intervention.

RESULTS

Fasting glucose and 2 h postprandial glucose levels were improved statistically in SHEG and HEG groups after intervention (p < 0.05). Differences in SHEG were statistically higher than HEG (p < 0.017). When the HEG and CG were compared, there was no superiority between the two groups in all outcome measures except the physical health. Additionally, there were no statistically significant differences in values of cesarean birth and preterm birth between groups (p > 0.05).

CONCLUSIONS

This study revealed that pregnant women should be under the supervision of physiotherapists while doing home exercises. Clinical Trial Registration The trial was approved by the registration of ClinicalTrials.gov and registration number: NCT05195333.

Does Dietitian Involvement During Pregnancy Improve Birth Outcomes? A Systematic Review

Maternal diet during pregnancy can have a significant impact on maternal and offspring health. As nutrition counselling is an important component of prenatal care, registered dietitians (RDs) are uniquely trained professionals who can provide personalized nutrition counselling customized to an individual's sociocultural needs. The objective of this systematic review was to determine if RD involvement during pregnancy is associated with a lower prevalence of adverse birth outcomes in the United States and Canada. The review was conducted through a search of four databases: PubMed, CINAHL, Embase, and Web of Science. A total of 14 studies were identified. Women had a lower prevalence of low birth weight and preterm infants when RDs were involved during prenatal care. While RD involvement during pregnancy was not associated with macrosomia, more research is needed to assess its relationship with small for gestational age, large for gestational age, and infant mortality. Future research should also investigate the specific dietary advice provided by RDs and the extent and timing of their involvement throughout pregnancy to better understand the mechanisms surrounding nutrition counselling, in utero development, and health outcomes.

Community-based non-pharmacological interventions for pregnant women with gestational diabetes mellitus: a systematic review

BACKGROUND

Non-pharmacological interventions are the first line of Gestational diabetes mellitus (GDM) management. Community-based interventions are cheaper, more accessible, with higher patient satisfaction.

OBJECTIVES

To systematically review community-based non-pharmacological interventions and evaluate their effectiveness for GDM.

SEARCH STRATEGY

Twelve bibliographic databases and reference list of related studies from inception until January 2022.

SELECTION CRITERIA

All primary studies of community-based non-pharmacological interventions for GDM reported in English which investigated any behavioural or clinical outcome(s).

DATA COLLECTION AND ANALYSIS

Data were extracted using modified Cochrane's data extraction template. Studies were evaluated using Cochrane Collaboration's risk of bias tool. Narrative synthesis was used to summarise findings. This study is registered with PROSPERO (CRD42021257634).

MAIN RESULTS

Twenty-seven studies involving 6,242 pregnant women with GDM investigated self-management programmes, medical nutrition/diet therapy, exercise/physical activity, combined diet and exercise, calcium plus vitamin D supplementation, and continuous glucose monitoring. Self-management programmes were more effective than routine care in improving self-efficacy, two-hour postprandial blood glucose, and lifestyle behaviours but were as effective as routine care in improving infant birth weight. Self-management programmes were superior to or as effective as usual care in improving fasting blood glucose, blood glucose control, glycated haemoglobin, macrosomia, and preterm delivery. Medical nutrition/diet therapy was more effective than usual care in improving postprandial blood glucose levels. Postprandial blood glucose levels were better improved by regular supervised exercise plus daily brisk walks or a daily walking intervention than routine obstetric care or no treatment. The effects of exercise/physical activity programmes were mostly inconsistent for other outcomes. Diet and exercise were superior to diet alone in reducing maternal weight gain although there were similar outcomes for other pregnancy and foetal outcomes. Limited or conflicting evidence was found for other outcomes and interventions including calcium and vitamin D supplementation and continuous glucose monitoring intervention.

CONCLUSIONS

Community-based non-pharmacological interventions are more effective than placebo; and are more or as effective as usual care. Self-management programmes and medical nutrition/diet therapy had the most promising GDM outcomes.

FUNDING

There was no funding for this study. The study design, data collection, data analysis and interpretation, and writing of this manuscript were not influenced externally by any funder.

DNA methylation and expression profiles of placenta and umbilical cord blood reveal the characteristics of gestational diabetes mellitus patients and offspring

BACKGROUND

Gestational diabetes mellitus (GDM) is a common pregnancy-specific disease and is growing at an alarming rate worldwide, which can negatively affect the health of pregnant women and fetuses. However, most studies are limited to one tissue, placenta or umbilical cord blood, usually with one omics assay. It is thus difficult to systematically reveal the molecular mechanism of GDM and the key influencing factors on pregnant women and offspring.

RESULTS

We recruited a group of 21 pregnant women with GDM and 20 controls without GDM. For each pregnant woman, reduced representation bisulfite sequencing and RNA-seq were performed using the placenta and paired neonatal umbilical cord blood specimens. Differentially methylated regions (DMRs) and differentially expressed genes (DEGs) were identified with body mass index as a covariate. Through the comparison of GDM and control samples, 2779 and 141 DMRs, 1442 and 488 DEGs were identified from placenta and umbilical cord blood, respectively. Functional enrichment analysis showed that the placenta methylation and expression profiles of GDM women mirrored the molecular characteristics of "type II diabetes" and "insulin resistance." Methylation-altered genes in umbilical cord blood were associated with pathways "type II diabetes" and "cholesterol metabolism." Remarkably, both DMRs and DEGs illustrated significant overlaps among placenta and umbilical cord blood samples. The overlapping DMRs were associated with "cholesterol metabolism." The top-ranking pathways enriched in the shared DEGs include "growth hormone synthesis, secretion and action" and "type II diabetes mellitus."

CONCLUSIONS

Our research demonstrated the epigenetic and transcriptomic alternations of GDM women and offspring. Our findings emphasized the importance of epigenetic modifications in the communication between pregnant women with GDM and offspring, and provided a reference for the prevention, control, treatment, and intervention of perinatal deleterious events of GDM and neonatal complications.

Facilitators, Barriers, and Structural Determinants of Physical Activity in Nulliparous Pregnant Women: A Qualitative Study

Aims & Backgrounds. Reduced physical activity in pregnant women is highly stemmed from their misconceptions and attitudes during pregnancy. This study is aimed at recognizing the facilitators, barriers, and structural factors that influence activity among pregnant women. Participants & Methods. This qualitative study was conducted from January to June 2020 in nulliparous pregnant women. Forty participants selected randomly from the Pounak Health Center of Tehran City, Iran, answered open-ended questions about the obstacles that deprived them of physical activity during pregnancy. Data were analyzed by MAXQDA 12 software. Findings. 620 primary codes, 42 secondary codes, 11 subthemes, and 6 themes were extracted. These themes were divided into the PEN-3 categories: facilitators, barriers, and structural factors. The nurture factors as facilitators had communication and support from others as subthemes. Barriers consisted of sociocultural (participate in pregnancy class with a companion, social beliefs, and culture of poverty), socioeconomic (financial problems), and individual factors (physical, psychoemotional, and spiritual dimensions), and structural factors consisted of environmental (equipment) and organizational (possibilities in health centers) factors. Conclusion. Lack of awareness and misinformation, accessibility obstacles, and economic problems are the worst physical activity barriers during pregnancy. Being among other pregnant women and the physicians' recommendations are the best facilitators of physical activity during pregnancy.

Effects of resistance exercise on blood glucose level and pregnancy outcome in patients with gestational diabetes mellitus: a randomized controlled trial

INTRODUCTION

To date, the effects of resistance exercise on diabetes-related parameters (blood glucose level and insulin use) and pregnancy outcome in participants with gestational diabetes mellitus (GDM) have not been compared with those of aerobic exercise. To investigate the effect of resistance exercise versus aerobic exercise on blood glucose level, insulin utilization rate, and pregnancy outcome in patients with GDM.

RESEARCH DESIGN AND METHODS

From December 2019 to December 2020, 100 pregnant women with GDM were selected and divided into a resistance exercise group (49 patients) and an aerobic exercise group (51 patients) randomly. The aerobic exercise group received an aerobic exercise intervention, while the resistance exercise group received a resistance exercise intervention. Both groups received exercise intervention for 50-60 min, 3 times per week, lasting for 6 weeks. In addition, patients in both groups received the same routine care, including personalized dietary intervention, online education, and school courses for pregnant women.

RESULTS

The blood glucose level in the resistance exercise group and the aerobic exercise group was lower after the intervention than before the intervention (p<0.05). After the intervention, no significant differences were observed in the fasting blood glucose level, insulin utilization rate, and incidence of adverse pregnancy outcomes between the two groups (p>0.05); however, significant differences were noted in 2-hour postprandial blood glucose level and exercise compliance between the two groups (p<0.05), with the resistance exercise group showing better outcomes than the aerobic exercise group.

CONCLUSIONS

Resistance exercise is more compliant for pregnant women with GDM than aerobic exercise; hence, it is necessary to popularize resistance exercise in this specific population group. Long-term effects of resistance exercise should be evaluated in future studies.

TRIAL REGISTRATION NUMBER

ChiCTR 1900027929.

Exercise alters cardiovascular and renal pregnancy adaptations in female rats born small on a high-fat diet

Intrauterine growth restriction programs adult cardiorenal disease, which may be exacerbated by pregnancy and obesity. Importantly, exercise has positive cardiovascular effects. This study determined if high-fat feeding exacerbates the known adverse cardiorenal adaptations to pregnancy in rats born small and whether endurance exercise can prevent these complications. Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted) or sham (Control) surgery on embryonic day 18 (E18) in Wistar-Kyoto rats. Female offspring consumed a Chow or high-fat diet (HFD) from weaning and were randomly allocated to either a sedentary (Sedentary) or an exercise protocol at 16 wk; exercised before and during pregnancy (Exercise), or exercised during pregnancy only (PregEx). Systolic blood pressure was measured prepregnancy and rats were mated at 20 wk. During pregnancy, systolic blood pressure (E18) and renal function (E19) were assessed. Sedentary HFD Control females had increased estimated glomerular filtration rate (eGFR) compared with Chow. Compared with Control, Sedentary-Restricted females had increased eGFR, which was not influenced by HFD. Renal function was not affected by exercise and prepregnancy blood pressure was not altered. Restricted Chow-fed dams and dams fed a high-fat diet had a greater reduction in systolic blood pressure during late gestation, which was only prevented by Exercise. In summary, high-fat fed females born small are at a greater risk of altered cardiorenal adaptations to pregnancy. Although cardiovascular dysfunction was prevented by Exercise, renal dysfunction was not affected by exercise interventions. This study highlights that modifiable risk factors can have beneficial effects in the mother during pregnancy, which may impact fetal growth and development.

Nutrition Management of Gestational Diabetes Mellitus

Medical nutrition therapy (MNT) is the bedrock for the management of gestational diabetes mellitus (GDM). Several different types of dietary approaches are used globally, and there is no consensus among the various professional groups as to what constitutes an ideal approach. The conventional approach of limiting carbohydrates at the cost of increasing energy from the fat source may not be most optimal. Instead, allowing higher levels of complex, low-to-medium glycaemic index carbohydrates and adequate fibre through higher consumption of vegetables and fruits seems more beneficial. No particular diet or dietary protocol is superior to another as shown in several comparative studies. However, in each of these studies, one thing was common - the intervention arm included more intensive diet counselling and more frequent visits to the dieticians. For MNT to work, it is imperative that diet advice and nutrition counselling is provided by a dietician, which is easy to understand and use and includes healthy food options, cooking methods, and practical guidance that empower and motivate to make changes towards a healthy eating pattern. Various simple tools to achieve these objectives are available, and in the absence of qualified dieticians, they can be used to train other health care professionals to provide nutrition counselling to women with GDM. Given the impact of GDM on the future health of the mother and offspring, dietary and lifestyle behaviour changes during pregnancy in women with GDM are not only relevant for immediate pregnancy outcomes, but continued adherence is also important for future health.

Analysis of the Impact of the Confinement Resulting from COVID-19 on the Lifestyle and Psychological Wellbeing of Spanish Pregnant Women: An Internet-Based Cross-Sectional Survey

(1) Background: This study aimed to analyze the impact of the confinement due to the COVID-19 pandemics on the eating, exercise, and quality-of-life habits of pregnant women. (2) Methods: This was an internet-based cross-sectional survey which collected information about adherence to the Mediterranean diet, physical exercise, health-related quality of life (HRQoL), and perceived obstacles (in terms of exercise, preparation for delivery, and medical appointments) of pregnant women before and after the confinement. The survey was conducted in 18–31 May 2020. (3) Results: A total of 90 pregnant women participated in this study. There was a significant decrease in the levels of physical activity (p < 0.01) as well as in HRQoL (p < 0.005). The number of hours spent sitting increased by 50% (p < 0.001), 52.2% were unable to attend delivery preparation sessions because these had been cancelled. However, there were no significant differences in the eating pattern of these women (p = 0.672). Conclusions: These results suggest the need to implement specific online programs to promote exercise and reduce stress, thus improving the HRQoL in this population, should similar confinements need to occur again for any reason in the future.

Exercise during pregnancy: a comparative review of guidelines

Exercise during pregnancy may be beneficial provided that there are no contraindications. The aim of this study was to summarize and compare recommendations regarding exercise in pregnancy. Thus, a comparative descriptive review was conducted and included guidelines by the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. All compared guidelines recommend that pregnant women without contraindications should undertake physical activities regularly, however, the type of workout performed should be adjusted based on the previous exercise experience and the physical condition of each pregnant woman. A variation among the reviewed guidelines was identified on appropriate and inappropriate activities and on indications to interrupt exercise. To summarize, the adoption of an international up-to-date consensus regarding appropriate exercise during pregnancy may be beneficial in ensuring the safety of the pregnant women while promoting their physical and mental health.

Expression and correlation of Chemerin and FABP4 in peripheral blood of gestational diabetes mellitus patients

Expression and correlation of Chemerin and fatty acid-binding protein 4 (FABP4) in peripheral blood of gestational diabetes mellitus (GDM) patients were investigated. Sixty patients with GDM from March 2018 to March 2019 in the People's Hospital of Zhangqiu Area were selected as the study group (SG) and another 50 healthy pregnant women corresponding to their age and pregnancy were selected as the control group (CG). Enzyme linked immunosorbent assay (ELISA) was used to detect the expression of Chemerin and FABP4 in serum. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of Chemerin and FABP4 in peripheral blood for GDM patients. Pearson's correlation coefficient was used to analyze the correlation between Chemerin and FABP4 and the correlation between Chemerin and inflammatory factors such as interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). Expression of Chemerin and FABP4 in peripheral blood of GDM patients were significantly higher than those in CG. The AUC of GDM patients diagnosed with Chemerin and FABP4 in peripheral blood was 0.820 and 0.814, while the AUC of GDM patients diagnosed with Chemerin combined with FABP4 in peripheral blood was 0.904. Expression of inflammatory factors IL-6 and TNF-α in the SG were significantly higher than those in the CG. Chemerin in the SG was positively correlated with FABP4 and positively correlated with inflammatory factors IL-6 and TNF-α. Patients with advanced age (≥35 years), family history of diabetes, hyperlipidemia, high pre-pregnancy BMI, high fasting blood glucose, high Chemerin and high FABP4 expression have high risk of GDM. In conclusion, Chemerin and FABP4 were upregulated in the peripheral blood of GDM patients. There was a positive correlation between the two and a positive correlation with the inflammatory factors IL-6 and TNF-α.

Type 2 Diabetes in Pregnancy

Hyperglycemia is common during pregnancy, involving multisystem adaptations. Pregnancy-induced metabolic changes increase insulin resistance. Pregnancy-induced insulin resistance adds to preexisting insulin resistance. Preexisting pancreatic β-cell defect compromises the ability to enhance insulin secretion, leading to hyperglycemia. Women with type 2 DM have similar rates of major congenital malformations, stillbirth, and neonatal mortality, but an even higher risk of perinatal mortality. In utero type 2 DM exposure confers greater risk and reduces time to development of type 2 DM in offspring. Preconception care to improve metabolic control in women with type 2 diabetes is critical.

Walking for health during pregnancy: A literature review and considerations for future research

Walking is the most commonly chosen type of physical activity (PA) during pregnancy and provides several health benefits to both mother and child. National initiatives have promoted the importance of walking in general, but little emphasis is directed toward pregnant women, the majority of whom are insufficiently active. Pregnant women face a variety of dynamic barriers to a physically active lifestyle, some of which are more commonly experienced during specific times throughout the pregnancy experience. Walking is unique in that it appears resistant to a number of these barriers that limit other types of PA participation, and it can be meaningfully integrated into some transportation and occupational activities when leisure-time options are unavailable. Preliminary intervention work suggests that walking programs can be effectively adopted into a typical pregnancy lifestyle. However, a great deal of work remains to administer successful pregnancy walking interventions, including developing and using validated methods of PA and walking assessment. This narrative review discusses the unique advantages of walking during pregnancy, provides recommendations for future intervention work, and outlines the need for pregnancy-focused community walking initiatives. Standard search procedures were followed to determine sources from the literature specific to walking during pregnancy for use in each section of this review.

Dietary and exercise interventions and glycemic control and maternal and newborn outcomes in women diagnosed with gestational diabetes: Systematic review

Gestational diabetes mellitus (GDM) is one of the most common complication of pregnancy and can lead to significant perinatal mortalities as well as long term risk of comorbidities for both mother and her offspring. This systematic review aimed to explore whether combined diet and exercise interventions are associated with improved glycemic control and/or improved maternal and newborn outcomes in women with GDM when compared to dietary interventions. A search on combined diet and exercise interventions during pregnancy in women with GDM was performed in 3 electronic databases: PubMed (NCBI), ScienceDierct, and the Cochrane Library. Evaluated outcomes were fasting blood glucose levels, postprandial blood glucose levels, glycated hemoglobin percentages, total weight gain during pregnancy, proportion of caesarean delivery, proportion of patients needing insulin, neonatal birth weight, proportion of macrosomia, neonatal hypoglycemia, and preterm birth. This systematic review identified eight randomized, controlled trials involving 592 pregnant women and 350 infants. The risk of bias of the included trials ranged from high to low. The combined diet and exercise interventions reduced fasting and postprandial blood glucose levels when compared to dietary interventions. No significant differences were reported in the selected trials regarding total weight gain during pregnancy, cesarean section, neonatal birth weight, macrosomia, neonatal hypoglycemia, and preterm birth between diet plus exercise and diet groups. The combination of diet and exercise interventions help to control postprandial blood glucose concentration in women diagnosed with GDM, but did not change either maternal or newborn outcomes. REGISTRATION: PROSPERO CRD42018109896.

Non-Medical Strategies to Improve Pregnancy Outcomes of Women with Gestational Diabetes Mellitus: A literature review

This review aimed to examine the literature related to non-medical strategies used to improve pregnancy outcomes of women with gestational diabetes mellitus (GDM) and to determine the risk of bias of the selected studies. Treatment for GDM is changing due to the increased prevalence of GDM-related maternal and neonatal complications. A growing body of evidence suggests that early detection, aggressive monitoring and management of GDM using non-medical strategies can greatly improve outcomes for pregnant women and their babies. PubMed^® (National Library of Medicine, Bethesda, Maryland, USA), Cumulative Index to Nursing and Allied Health Literature^® (EBSCO Information Services, Ipswich, Massachusetts, USA), SCOPUS^® (Elsevier, Amsterdam, Netherlands) and other electronic databases were searched for relevant literature published between 2005-2015. A total of 15 studies on women with GDM that met the inclusion criteria were included in this review and assessment of risk of bias was performed for each study. The results of the studies were consistent with findings of significant improvement in maternal and neonatal outcomes when diet was combined with moderate exercise, self-monitoring of blood glucose and individualised health education. Future intervention studies in this area should be focussed on identifying and implementing factors that enhance and encourage adherence to the healthy behaviours mentioned above.

Prenatal Intervention with Partial Meal Replacement Improves Micronutrient Intake of Pregnant Women with Obesity

A behavioral lifestyle intervention with partial meal replacement reduced excess gestational weight gain in ethnically diverse women with overweight/obesity, but the effects on micronutrient intake remained unknown. A secondary analysis of a randomized, controlled trial tested whether the intervention improved micronutrient intake relative to usual care. Pregnant women (n = 211; 30.5 years of age, body mass index, BMI, of 32.0 kg/m²) were enrolled and randomized within site and ethnicity (40% were Hispanic) into intervention (n = 102) or usual care (n = 109) groups. Two 24 h dietary recalls were conducted on random days at study entry and late pregnancy (35–36 weeks gestation). Nutrient adequacy was defined using the Estimated Average Requirement cut-point method. At study entry and including prenatal vitamins, ≥90% of participants reported inadequate intake of vitamins D and E and iron; 40–50% reported inadequate intake of calcium, protein, vitamins A, C, B₆, folate, magnesium, and zinc. From study entry to late pregnancy, the behavioral intervention with partial meal replacement increased the overall intake of vitamins A, E, and D and copper and reduced the odds of inadequate intake of calcium (odds ratio (OR) = 0.37 (0.18, 0.76)), vitamins A (OR = 0.39 (0.21, 0.72)) and E (OR = 0.17 (0.06, 0.48)), and magnesium (OR = 0.36 (0.20, 0.65)). A behavioral intervention with partial meal replacement during pregnancy improved the intake of several micronutrients in Hispanic and non-Hispanic women with overweight/obesity.

Ripple Effect of Lifestyle Interventions During Pregnancy on Untreated Partners' Weight

OBJECTIVE

Weight-loss interventions have a positive "ripple effect" on untreated partners' weight, but ripple effects in pregnancy are unknown. The objective of this study was to determine whether prenatal lifestyle interventions that reduce gestational weight gain in pregnant women have a positive ripple effect on untreated partners' weight.

METHODS

Two clinical trials with the same outcome measures randomly assigned pregnant women to a lifestyle intervention or usual care. Untreated partners were randomly assigned according to their pregnant partner's group allocation and were assessed at study entry (~13 weeks' gestation), 35 weeks' gestation, and 6 and 12 months after delivery.

RESULTS

A total of 122 partners (100% male, 23% Hispanic, 82% married, and 48% with obesity) were randomly assigned to the intervention (n = 59) or usual care (n = 63). There was no intervention or intervention-by-time interaction effect on partner weight (P = 0.795). Partner weight changes were not statistically significant (P = 0.120) from study entry to 35 weeks' gestation (mean 0.19 kg; 95% CI: -0.73 to 1.24) or to 12 months after delivery (mean 0.82 kg; 95% CI: -0.26 to 1.91).

CONCLUSIONS

There was no evidence of a ripple effect on partner weight. In a self-selected sample, partners of pregnant women appeared not to experience sympathy weight gain.

How diet, physical activity and psychosocial well-being interact in women with gestational diabetes mellitus: an integrative review

Background

Gestational Diabetes Mellitus (GDM) is associated with future cardio-metabolic risks for the mother and her child. In addition, one-third of women with recent GDM develop postpartum depression. Given these adverse impacts of GDM on the health of the mother and her offspring, it is important to intervene on modifiable factors, such as diet, physical activity, and psychosocial well-being. This integrative review therefore explored evidence on how these modifiable factors interact in women with GDM and their offspring, and how effective combined interventions are on reducing adverse impacts of GDM.

Methods

A comprehensive search strategy included carefully selected terms that corresponded to the domains of interest (diet, physical activity and psychosocial well-being). The databases searched for articles published between 1980 and February 2018 were: CINAHL, PsycINFO, Embase, Pubmed and Cochrane. Studies that were included in this review were either observational or intervention studies that included at least two domains of interest. Articles had to at least report data on maternal outcomes of women with GDM.

Results

The search strategies identified 14′419 citations after excluding duplicates. After screening titles and then abstracts, 114 articles were selected for detailed evaluation of their full text, and 16 were included in this review: two observational and 14 intervention studies. Results from observational studies showed that psychosocial well-being (social support and self-efficacy) were positively associated with physical activity and dietary choice. Intervention studies always included diet and physical activity interventions, although none integrated psychosocial well-being in the intervention. These lifestyle interventions mostly led to increased physical activity, improved diet and lower stress perception. Many of these lifestyle interventions also reduced BMI and postpartum diabetes status, improved metabolic outcomes and reduced the risk of preterm deliveries and low birth weight.

Conclusion

This integrative review showed that psychosocial well-being interacted with diet as well as with physical activity in women with GDM. We recommend that future studies consider integrating psychosocial well-being in their intervention, as observational studies demonstrated that social support and self-efficacy helped with adopting a healthy lifestyle following GDM diagnosis.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2185-y) contains supplementary material, which is available to authorized users.

Maternal exercise and growth restriction in rats alters placental angiogenic factors and blood space area in a sex-specific manner

Fetal growth and development are dependent on adequate placental nutrient transfer. The surface area of the placental villous network is a key determinant of nutrient exchange, which is regulated by vasculogenic and angiogenic factors. These factors are altered by intrauterine growth restriction (IUGR) and maternal obesity in both the first (F1) and second (F2) generations. We investigated the impact of endurance exercise in IUGR dams fed a High-fat diet on placental vasculogenesis and angiogenesis. Uteroplacental insufficiency (Restricted) or sham (Control) surgery was induced on embryonic day (E) 18 in Wistar-Kyoto rats. F1 offspring were fed a Chow or High-fat diet from weaning, and at 16 weeks were further allocated an exercise protocol; Sedentary, Exercised prior to and during pregnancy (Exercise), or Exercised during pregnancy only (PregEx). Females were mated (20 weeks) and F2 placentae collected at E20. Maternal Restriction, High-fat feeding and Exercise had a minimal impact on placental regulators of vasculogenesis and angiogenesis. However, Restriction increased placental labyrinth tissue area in Chow-fed dams. PregEx induced overt adaptations, including increased VEGFA and decreased PLGF protein expression, and reduced blood space area. These alterations were sex-dependent and associated with alterations in miRNA27a, a known regulator of VEGF translation. These data highlight that maternal exercise initiated during pregnancy (PregEx) causes alterations in placental vasculogenesis and angiogenesis in a sex-dependent manner, with minimal Restriction and maternal diet effects. However, further investigation is required to determine if these adaptations are beneficial or harmful for maternal and fetoplacental outcomes.

Guidelines for exercise during normal pregnancy and gestational diabetes: a review of international recommendations

OBJECTIVE

Τo summarize and present the main guidelines for exercise during normal pregnancy and pregnancy complicated by gestational diabetes mellitus (GDM).

METHODS

Relevant guidelines were retrieved through the electronic databases PubMed (MEDLINE), CENTRAL (Cochrane), and Embase; reference sections of the retrieved publications; proceedings of the main congresses in the field; and websites of relevant organizations published during the years 2000-2018.

RESULTS

All guidelines recommend aerobic training from 60 to 150 min/week, with an upper limit of 30 min/day. Exercise is safe, even on a daily basis. Resistance exercise is suggested by five national guidelines (Australia, Canada, Denmark, Norway, and the UK). Discrepancies exist regarding the recommended intensity of exercise. Canada, Japan, Spain, and the UK use both objective (heart rate and maximum oxygen consumption) and subjective criteria (Borg's Scale and talk test) to determine the effectiveness and safety of exercise. Only Canada provides specific recommendations, according to the woman's age and level of physical condition. Women with GDM on no insulin treatment do not need to take extra precautions during exercise. However, due to their condition of hyperglycemia, they must comply with the recommendation issued for type 2 diabetes. The prescription and supervision of exercise should be carried out in a similar way as for uncomplicated pregnancies. Finally, women with GDM on insulin treatment need to follow the same recommendations as for those for pregnant women with type 1 diabetes.

CONCLUSION

Health professionals must be informed about the correct planning and execution of physical exercise programs so as to safely achieve the maximum effectiveness of exercise-induced health-related benefits in pregnant women.

Effects of prenatal exercise on fetal heart rate, umbilical and uterine blood flow: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis examining the influence of acute and chronic prenatal exercise on fetal heart rate (FHR) and umbilical and uterine blood flow metrics.

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 [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcomes (FHR, beats per minute (bpm); uterine and umbilical blood flow metrics (systolic:diastolic (S/D) ratio; Pulsatility Index (PI); Resistance Index (RI); blood flow, mL/min; and blood velocity, cm/s)).

RESULTS

'Very low' to 'moderate' quality evidence from 91 unique studies (n=4641 women) were included. Overall, FHR increased during (mean difference (MD)=6.35bpm; 95% CI 2.30 to 10.41, I²=95%, p=0.002) and following acute exercise (MD=4.05; 95% CI 2.98 to 5.12, I²=83%, p<0.00001). The incidence of fetal bradycardia was low at rest and unchanged with acute exercise. There were no significant changes in umbilical or uterine S/D, PI, RI, blood flow or blood velocity during or following acute exercise sessions. Chronic exercise decreased resting FHR and the umbilical artery S/D, PI and RI at rest.

CONCLUSION

Acute and chronic prenatal exercise do not adversely impact FHR or uteroplacental blood flow metrics.

Glucose responses to acute and chronic exercise during pregnancy: a systematic review and meta-analysis

Objective

To perform a systematic review and meta-analysis to explore the relationship between prenatal exercise and glycaemic control.

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 and reviews) 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 acute or chronic exercise, alone (‘exercise-only’) or in combination with other intervention components (eg, dietary; ‘exercise+cointervention’) at any stage of pregnancy), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (glycaemic control).

Results

A total of 58 studies (n=8699) were included. There was ‘very low’ quality evidence showing that an acute bout of exercise was associated with a decrease in maternal blood glucose from before to during exercise (6 studies, n=123; mean difference (MD) −0.94 mmol/L, 95% CI −1.18 to −0.70, I2=41%) and following exercise (n=333; MD −0.57 mmol/L, 95% CI −0.72 to −0.41, I2=72%). Subgroup analysis showed that there were larger decreases in blood glucose following acute exercise in women with diabetes (n=26; MD −1.42, 95% CI −1.69 to −1.16, I2=8%) compared with those without diabetes (n=285; MD −0.46, 95% CI −0.60 to −0.32, I2=62%). Finally, chronic exercise-only interventions reduced fasting blood glucose compared with no exercise postintervention in women with diabetes (2 studies, n=70; MD −2.76, 95% CI −3.18 to −2.34, I2=52%; ‘low’ quality of evidence), but not in those without diabetes (9 studies, n=2174; MD −0.05, 95% CI −0.16 to 0.05, I2=79%).

Conclusion

Acute and chronic prenatal exercise reduced maternal circulating blood glucose concentrations, with a larger effect in women with diabetes.

Gestational diabetes mellitus: Multi-disciplinary treatment approaches

Gestational diabetes mellitus (GDM) is the most common metabolic disease of pregnancy, associated with several perinatal complications. Adequate glycemic control has been proved to decrease risk of GDM-related complications. Several studies have shown the beneficial effect of exercise and medical nutrition treatment on glycemic and weight control in GDM-affected women. Moreover, pharmacological agents, such as insulin and specific oral anti-diabetic agents can be prescribed safely during pregnancy, decreasing maternal blood glucose and, thus, perinatal adverse outcomes. Multi-disciplinary treatment approaches that include both lifestyle modifications (medical nutritional therapy and daily physical exercise) and pharmacological treatment, in cases of failure of the former, constitute the most effective approach. Insulin is the gold standard pharmacological agent for GDM treatment. Metformin and glyburide are two oral anti-diabetic agents that could serve as alternative, although not equal in terms of effectiveness and safety, treatment for GDM. As studies on short-term safety of metformin are reassuring, in some countries it is considered as first-line treatment for GDM management. More studies are needed to investigate the long-term effects on offspring. As safety issues have been raised on the use of glyburide during pregnancy, it must be used only when benefits surpass possible risks.

Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews

BACKGROUND

Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies.

OBJECTIVES

To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies.

METHODS

We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded.Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data.

MAIN RESULTS

We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high- to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM.EffectiveLifestyle versus usual careLifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality).PromisingNo evidence for any outcome for any comparison could be classified to this category.Ineffective or possibly harmful Lifestyle versus usual careLifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality).Exercise versus controlExercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality).Insulin versus oral therapyInsulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality).Probably ineffective or harmful interventionsInsulin versus oral therapyFor insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality).InconclusiveLifestyle versus usual careThe evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality).Exercise versus controlThe evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality).Insulin versus oral therapyThe evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes.Insulin versus dietThe evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality).Insulin versus insulinThe evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality).No conclusions possibleNo conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low-quality.

AUTHORS' CONCLUSIONS

Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.

A systematic review of dietary interventions for gestational weight gain and gestational diabetes in overweight and obese pregnant women

PURPOSE

The number of overweight and obese women is increasing in the obstetric population. The aim of this study was to review studies that reported results related to the efficacy of dietary interventions on gestational weight gain (GWG) or the prevention of gestational diabetes (GDM) in overweight and obese women.

METHODS

The search was performed using the CINAHL, PubMed, Scopus and Medic electronic databases and limited to the years between 2000 and March 2016. This systematic review includes 15 research articles of which 12 were randomized controlled trials, and three were controlled trials. Three main categories emerged as follows: (1) the types of interventions, (2) the contents of the interventions and (3) the efficacy of the intervention on GWG and the prevention of GDM. The quality of the selected studies was evaluated using the AHRQ Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews.

RESULTS

Of the selected 15 studies, eight included a specified diet with limited amounts of nutrients or energy, and the others included a dietary component along with other components. Ten studies reported significant differences in the measured outcomes regarding GWG or the prevention of GDM between the intervention and the control groups.

CONCLUSIONS

This review confirms the variability in the strategies used to deliver dietary interventions in studies aiming to limit GWG and prevent GDM in overweight and obese women. Inconsistency in the provider as well as the content of the dietary interventions leaves the difficulty of summarizing the components of effective dietary interventions.

Randomized controlled clinical trial of behavioral lifestyle intervention with partial meal replacement to reduce excessive gestational weight gain

Background

Behavioral lifestyle interventions during pregnancy can prevent excessive gestational weight gain (GWG) in women with normal weight; however, effective interventions to reduce GWG in ethnically diverse women with obesity are lacking.

Objective

A randomized controlled trial was conducted to test whether a behavioral lifestyle intervention with partial meal replacement reduces GWG rate in Hispanic and non-Hispanic women with overweight or obesity relative to enhanced usual care.

Design

Participants (n = 257) were recruited in San Luis Obispo, California, and Providence, Rhode Island, between November 2012 and May 2016. Participants were pregnant (mean ± SD: 13.6 ± 1.8 wk of gestation) with overweight or obesity and had a mean age of 30.3 y; 41.6% of participants were Hispanic. Women were randomly assigned within site and by ethnicity to enhanced usual care (n = 128) or to a behavioral lifestyle intervention with partial meal replacement (n = 129). The primary outcome was GWG per week of observation. Secondary outcomes were proportions exceeding Institute of Medicine (IOM) guidelines for total GWG, changes in weight-control behaviors and cardiovascular disease risk factors, and incidence of pregnancy complications. Study retention was 99.6% (256 of 257).

Results

The intervention compared with usual care resulted in less mean ± SD weekly GWG (0.33 ± 0.25 compared with 0.39 ± 0.23 kg/wk; P = 0.02) and total GWG (9.4 ± 6.9 compared with 11.2 ± 7.0 kg; P = 0.03) and reduced the proportion of women who exceeded IOM guidelines for total GWG (41.1% compared with 53.9%; P = 0.03). No significant group × time × demographic subgroup (ethnicity, BMI, age, parity, and income) interactions were observed. Among intervention participants, greater meal replacement intake was related to reduced GWG rate (β = -0.07; 95% CI:-0.12, -0.03; P = 0.002). The intervention compared with usual care increased weight-control strategies (P < 0.0001) and cognitive restraint (P < 0.0001) and reduced triglycerides (P = 0.03).

Conclusion

Prenatal behavioral intervention with partial meal replacement significantly reduced GWG in Hispanic and non-Hispanic women with overweight or obesity. This trial was registered at www.clinicaltrials.gov as NCT01545934.

Influence of Land or Water Exercise in Pregnancy on Outcomes: A Cross-sectional Study

PURPOSE

This study aimed to compare the cross-sectional results from three experimental studies conducted on land, in water, and in mixed form (land + water) during pregnancy on maternal and newborn outcomes.

METHODS

A cross-sectional design was used to analyze the results of three randomized clinical trials in healthy pregnant women from Madrid (Spain) and Buenos Aires (Argentina). Five hundred and sixty-eight pregnant women were recruited. For each of the studies, the number of women in the exercise group totaled 107 for study 1 (land), 49 women for study 2 (water), and 101 women for study 3 (land + water). A total of 311 women represented the control group (CG) (pooled together from all three studies).

RESULTS

Total maternal weight gain was different between study 1 and CG (11.7 vs 13.4 kg, P = 0.001, Cohen's d = 0.38) as well as the percentage of pregnant women with excessive weight gain (20.6%, n = 22, vs 37.9%, n = 118, respectively, P = 0.005, χ = 16.6, OR = 0.42, 95% confidence interval = 0.25-0.71). The number of pregnant women with gestational diabetes in CG was significantly higher than that in studies 2 and 3 (CG n = 22/7.1%; study 2, n = 0/0%; and study 3, n = 1/1%; P = 0.03, χ = 8.9).

CONCLUSION

Exercise performed on land is more effective than aquatic activities in preventing excessive maternal weight gain, whereas combined programs (land + aquatic) or water exercise programs may be more effective in preventing gestational diabetes.

Determinants of physical activity frequency and provider advice during pregnancy

Background

Our aims were to (1) describe the frequency of physical activity and prenatal healthcare provider advice about physical activity during pregnancy and (2) examine determinants and correlates of 3rd trimester physical activity and receipt of physical activity advice.

Methods

We analyzed data from the 2008 Pregnancy Risk Assessment Monitoring System. We studied 2669 women from North Carolina and Colorado with data on physical activity frequency in the 3 months prior to pregnancy and during the 3rd trimester and 1584 women from Oklahoma with data on provider advice regarding physical activity during pregnancy. Respondents reported physical activity, defined as 30 min or more of exercise/physical activity (excluding vocationally related activity), in in these categories: <1 day/week, 1-4 days/week, and ≥5 days/week. We defined adherence to American College of Obstetrics & Gynecology (ACOG) criteria as physical activity ≥5 days/week in the 3rd trimester. We performed logistic regression analyses weighted for sampling and adjusted for socio-demographic factors.

Results

Forty-two percent of women in North Carolina and Colorado reported 3rd trimester physical activity <1 day/week, 42% 1-4 days/week, 9% ≥5 days/week; 7% reported being told not to exercise. Seventy-two percent of women in Oklahoma reported receiving physical activity advice from a prenatal care provider. Low activity frequency (<1 day/week) prior to pregnancy was strongly associated with low likelihood of ACOG guideline adherence in the 3rd trimester (aOR 0.10, 95% CU 0.04, 0.30 vs. 1–4 days/week). Underweight women were more likely to adhere to ACOG guidelines than normal weight women (aOR 2.27, 95% CI 1.36, 3.79). Overweight women were more likely to receive physical activity advice (aOR 2.9, 95% CI 1.3, 6.3 vs. normal weight), but obese women were not (aOR 0.65, 95% CI 0.4, 1.2).

Conclusions

Few women meet ACOG guideline criteria for physical activity during pregnancy. Improving physical activity and weight status prior to pregnancy may improve activity levels during pregnancy. Nearly one third did not receive advice about physical activity during prenatal care. Obese women were no more likely to receive advice than their normal weight counterparts, indicating the need for targeted physical activity counseling in this population.

Randomized Face-to-Face vs. Home Exercise Interventions in Pregnant Women with Gestational Diabetes

OBJECTIVES

Evaluate effects of a theoretically-based, semi-intensive (Face-to-Face; F2F) exercise intervention and minimum-contact (Home) exercise intervention to the standard care (Control) on exercise, its motivational determinants, blood glucose levels, and insulin use of pregnant women with gestational diabetes mellitus (GDM).

DESIGN

Randomized control trial with two intervention arms and control (standard care).

METHOD

Participants (N=65) were randomized to a Control (standard prenatal care/GDM dietary counseling), Home (standard care + phone education/support + home exercise), or F2F (standard care + on-site education/support + guided exercise with instructor on 2 days/week) group from ~20 weeks gestation to delivery. Assessments of exercise and motivational determinants were obtained at baseline (20-weeks gestation) and follow-up (32-weeks gestation). Blood glucose levels (fasting/postprandial mg/dL) and insulin use were extrapolated from medical records.

RESULTS

At the 32-week follow-up, the F2F group had significantly higher exercise min, pedometer steps/day, and motivational determinants (attitude, subjective norm, perceived control, intention) than controls (p's < .05) and significantly higher exercise min and subjective norm than the Home group (p's < .05); these effect sizes were medium-large (η2 = .11-.23). There was a medium effect (η2 = .13) on postprandial blood glucose at 36-weeks gestation with the F2F group having lower values than controls. Although not significant, the F2F group started insulin later (33 weeks gestation) than the Home (27 weeks) and Control (31 weeks) groups.

CONCLUSION

A theoretically-based, F2F exercise intervention has multiple health benefits and may be the necessary approach for promoting exercise motivation and behavior among GDM women.

Personalized Mobile Health Intervention for Health and Weight Loss in Postpartum Women Receiving Women, Infants, and Children Benefit: A Randomized Controlled Pilot Study

BACKGROUND

Prepregnancy maternal obesity and excessive weight gain during pregnancy lead to significant morbidities in mothers and their children. Mothers who never return to their prepregnancy weight begin subsequent pregnancies at a greater weight and have a larger propensity for excess gestational weight gain and postpartum weight retention.

METHODS

In this pilot study, 40 postpartum women credentialed to receive postpartum women, infants, and children (WIC) service were randomized to usual care ("WIC Moms") or a personalized health intervention delivered via a SmartPhone ("E-Moms"). Assessments, including body weight, vital signs, circumferences, and body composition, were completed at week 0 (6-8 weeks postpartum), week 8, and week 16.

RESULTS

Results are presented as change from week 0 at 16. As per the completers analysis, body weight change was not different between the groups (WIC Moms vs. E-Moms; 1.8 ± 0.9 vs. -0.1 ± 0.9 kg; p = 0.10), neither was the change in percent body fat (1.7 ± 0.6 vs. 0.1% ± 0.6%; p = 0.90) or waist/hip ratio (-0.01 ± 0.01 vs. -0.02 ± 0.01 cm; p = 0.60). However, due to notable variability in intervention adherence as the study progressed, participants were classified post hoc as having low (<40% adherence), medium (40%-70% adherence), or high adherence (>70% adherence). Participants with high intervention adherence (n = 5) had a significant reduction in body weight (-3.6 ± 1.6 vs. 1.8 ± 0.9 kg; p = 0.005) and percent body fat (-2.5 ± 1.0 vs. 1.7% ± 0.6%; p = 0.001) when compared to WIC Moms.

CONCLUSIONS

Overall, the E-Moms intervention was not able to decrease postpartum weight retention in women receiving WIC benefits compared to usual care received through the current WIC program. However, there is some evidence to suggest improved adherence to the intervention would improve weight management.

Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics

Across the Western World there is an increasing trend to postpone childbearing. Consequently, the negative influence of age on oocyte quality may lead to a difficulty in conceiving for many couples. Furthermore, lifestyle factors may exacerbate a couple's difficulty in conceiving due mainly to the metabolic influence of obesity; however, the negative impacts of low peripheral body fat, excessive exercise, the increasing prevalence of sexually transmitted diseases, and smoking all have significant negative effects on fertility. Other factors that impede conception are the perceived increasing prevalence of the polycystic ovary syndrome, which is further exacerbated by obesity, and the presence of uterine fibroids and endometriosis (a progressive pelvic inflammatory disorder) which are more prevalent in older women. A tendency for an earlier sexual debut and to have more sexual partners has led to an increase in sexually transmitted diseases. In addition, there are several genetic influences that may limit the number of oocytes within the ovary; consequently, by postponing attempts at childbearing, a limitation of oocyte number may become evident, whereas in previous generations with earlier conception this potentially reduced reproductive life span did not manifest in infertility. Environmental influences on reproduction are under increasing scrutiny. Although firm evidence is lacking however, dioxin exposure may be linked to endometriosis, phthalate exposure may influence ovarian reserve, and bisphenol A may interfere with oocyte development and maturation. However, chemotherapy or radiotherapy is recognized to lead to ovarian damage and predispose the woman to ovarian failure.

Moderate and Vigorous Intensity Exercise During Pregnancy and Gestational Weight Gain in Women with Gestational Diabetes

Objectives To estimate the associations of moderate and vigorous intensity exercise during pregnancy with the rate of gestational weight gain (GWG) from gestational diabetes (GDM) diagnosis to delivery, overall and stratified by prepregnancy overweight/obesity. Methods Prospective cohort study with physical activity reported shortly after the GDM diagnosis and prepregnancy weight and post-diagnosis GWG obtained from electronic health records (n = 1055). Multinomial logistic regression models in the full cohort and stratified by prepregnancy overweight/obesity estimated associations of moderate and vigorous intensity exercise with GWG below and above the Institute of Medicine's (IOM) prepregnancy BMI-specific recommended ranges for weekly rate of GWG in the second and third trimesters. Results In the full cohort, any participation in vigorous intensity exercise was associated with decreased odds of GWG above recommended ranges as compared to no participation [odds ratio (95 % confidence interval): 0.63 (0.40, 0.99)], with a significant trend for decreasing odds of excess GWG with increasing level of vigorous intensity exercise. Upon stratification by prepregnancy overweight/obesity, significant associations were only observed for BMI ≥ 25.0 kg/m(2): any vigorous intensity exercise, as compared to none, was associated with 54 % decreased odds of excess GWG [0.46 (0.27, 0.79)] and significant trends were detected for decreasing odds of GWG both below and above the IOM's recommended ranges with increasing level of vigorous exercise (both P ≤ 0.03). No associations were observed for moderate intensity exercise. Conclusions for Practice In women with GDM, particularly overweight and obese women, vigorous intensity exercise during pregnancy may reduce the odds of excess GWG.

Estimating the Recurrence Rate of Gestational Diabetes Mellitus (GDM) in Massachusetts 1998-2007: Methods and Findings

OBJECTIVES

Women with gestational diabetes mellitus (GDM) may be able to reduce their risk of recurrent GDM and progression to type 2 diabetes mellitus through lifestyle change; however, there is limited population-based information on GDM recurrence rates.

METHODS

We used data from a population of women delivering two sequential live singleton infants in Massachusetts (1998-2007) to estimate the prevalence of chronic diabetes mellitus (CDM) and GDM in parity one pregnancies and recurrence of GDM and progression from GDM to CDM in parity two pregnancies. We examined four diabetes classification approaches; birth certificate (BC) data alone, hospital discharge (HD) data alone, both sources hierarchically combined with a diagnosis of CDM from either source taking priority over a diagnosis of GDM, and both sources combined including only pregnancies with full agreement in diagnosis. Descriptive statistics were used to describe population characteristics, prevalence of CDM and GDM, and recurrence of diabetes in successive pregnancies. Diabetes classification agreement was assessed using the Kappa statistic. Associated maternal characteristics were examined through adjusted model-based t tests and Chi square tests.

RESULTS

A total of 134,670 women with two sequential deliveries of parities one and two were identified. While there was only slight agreement on GDM classification across HD and BC records, estimates of GDM recurrence were fairly consistent; nearly half of women with GDM in their parity one pregnancy developed GDM in their subsequent pregnancy. While estimates of progression from GDM to CDM across sequential pregnancies were more variable, all approaches yielded estimates of ≤5 %. The development of either GDM or CDM following a parity one pregnancy with no diagnosis of diabetes was <3 % across approaches. Women with recurrent GDM were disproportionately older and foreign born.

CONCLUSION

Recurrent GDM is a serious life course public health issue; the inter-pregnancy interval provides an important window for diabetes prevention.

Adherence to the DASH and Mediterranean diets is associated with decreased risk for gestational diabetes mellitus

OBJECTIVES

Few studies have examined the association between adherence to the Dietary Approaches to Stop Hypertension (DASH) or Mediterranean (MED) diets and prevalence of gestational diabetes mellitus (GDM). The aim of the present study was to evaluate the association between the two diets and GDM.

METHODS

In a case-control hospital-based study, pregnant women with (n = 200) and without (n = 260) GMD were recruited. An average of three 24-h dietary records were used to assess participants' dietary intakes. DASH scores were calculated based on the Fung method and MED scores were calculated using the Trichopoulou method. GDM was defined as fasting glucose >95 mg/dL or 1-h postprandial glucose >140 mg/dL for the first time in the pregnancy. The risk for GDM was assessed across tertiles of DASH and MED scores.

RESULTS

DASH and MED diets were negatively related to fasting blood glucose, hemoglobin A1c, and serum triacylglycerol concentrations. High-density lipoprotein cholesterol was significantly higher for those in the top tertile of the DASH diet but not the MED diet in comparison with the lowest tertile. Total serum cholesterol level was lower in the third tertile of the MED diet but not in the DASH diet. Participants in the highest tertile of the MED diet had 80% lower risk for GDM compared with those in the lowest tertile (Ptrend = 0.006). Greater adherence to the DASH eating plan was associated with 71% reduced risk for GDM (Ptrend = 0.006) after adjustment for potential confounders.

CONCLUSION

Adherence to either the DASH or Mediterranean diet is associated with decreased risk for GDM.

Fetal and maternal metabolic responses to exercise during pregnancy

Pregnancy is characterized by physiological, endocrine and metabolic adaptations creating a pseudo-diabetogenic state of progressive insulin resistance. These adaptations occur to sustain continuous fetal requirements for nutrients and oxygen. Insulin resistance develops at the level of the skeletal muscle, and maternal exercise, especially activity involving large muscle groups improve glucose tolerance and insulin sensitivity. We discuss the maternal hormonal and metabolic changes associated with a normal pregnancy, the metabolic dysregulation that may occur leading to gestational diabetes mellitus (GDM), and the consequences to mother and fetus. We will then examine the acute and chronic (training) responses to exercise in the non-pregnant state and relate these alterations to maternal exercise in a low-risk pregnancy, how exercise can be used to regulate glucose tolerance in women at risk for or diagnosed with GDM. Lastly, we present key exercise guidelines to help maintain maternal glucose regulation and suggest future research directions.

Maternal use of probiotics during pregnancy and effects on their offspring's health in an unselected population

Probiotics are used by women in the perinatal period and may improve balance of microbiota, with possible health benefits for both mother and baby. Characteristics and (health) behaviour patterns of mothers using probiotics during pregnancy, and health effects on their offspring, were investigated. Differences between mothers using probiotics during pregnancy and those who did not, were assessed. In total, 341 out of 2491 (13.7%) mothers reported use of probiotics during pregnancy. There were no significant differences in maternal features (gestation, age, ethnicity, education) between users and non-users. Logistic regression analyses showed that consumption of probiotics was significantly associated with use of homeopathic products [odds ratio (OR) 1.65, 95% confidence interval (CI) 1.17-2.33, p = 0.005], maternal history of smoking (OR 1.72, 95% CI 1.25-2.37, p = 0.001) and paternal history of smoking (OR 1.39, 95% CI 1.01-1.89, p = 0.05). Common disease symptoms during the first year of life in the offspring did not differ between both groups.

CONCLUSION

The use of probiotics or other health-related products without doctor's prescription during pregnancy might point to compensation for types of less favourable behaviour. Probiotic use during pregnancy does not seem to induce positive health effects in the offspring in an unselected population.

WHAT IS KNOWN

Aberrant microbiota compositions have been detected during critical periods when early programming occurs including pregnancy and early neonatal life. Probiotics modulate intestinal microbiota composition and are associated with positive health effects.

WHAT IS NEW

The use of probiotics or other health-related products without doctor's prescription during pregnancy is associated with and might point to compensation for types of less favourable behaviour. Probiotic use during pregnancy does not induce positive health effects in the offspring in this unselected population.

Preventing excessive weight gain during pregnancy and promoting postpartum weight loss: a pilot lifestyle intervention for overweight and obese African American women

To test the feasibility and acceptability of a theory-based lifestyle intervention designed to prevent excessive weight gain during pregnancy and promote weight loss in the early postpartum period in overweight and obese African American women. Sixteen pregnant women (≤18 weeks gestation) were recruited from prenatal clinics in Columbia, South Carolina in 2011 and assigned to a lifestyle intervention program. The intervention, guided by formative research, consisted of an individual counseling session followed by eight group sessions alternated with telephone counseling contacts that continued through 36 weeks of gestation. At 6-8 weeks postpartum, participants received a home visit and up to three counseling calls through week 12. Medical charts were reviewed for 38 contemporary controls who met the same inclusion criteria and attended the same prenatal clinics. Compared to controls, study participants gained less total weight, had a smaller weekly rate of weight gain across the 2nd and 3rd trimesters (0.89 vs. 0.96 lbs), and were less likely to exceed weight gain recommendations (56.3 vs. 65.8 %). At 12 weeks postpartum, study participants retained 2.6 lbs from their prepregnancy weight, half of study participants were at their prepregnancy weight or lower, and only 35 % retained ≥5 lbs. The intervention also demonstrated success in promoting physical activity and reducing caloric intake, and was well-received by participants. The initial results were promising. The lessons learned can help inform future studies. The efficacy of our intervention will be tested in a large randomized controlled trial.

Physical fitness, serum relaxin and duration of gestation

Background

Women are recommended to perform regular exercise during pregnancy but the impact of physical fitness on duration of gestation and miscarriage is inconsistent. In addition, a dose-response relation between the amount of weekly exercise and increased risk of miscarriage in early pregnancy has been observed. Previous studies have mostly used an epidemiologic method. Larger studies using careful measurement of physical fitness are needed. Besides physical fitness, maternal circulating concentrations of the hormone relaxin have been associated with decreased duration of gestation.

Methods

A prospective cohort including 20 women with miscarriage and 460 women with spontaneous onset of labour, recruited from maternal health care centres in central Sweden, were examined in early pregnancy regarding estimated absolute peak oxygen uptake (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{V}{O}_2 $$\end{document}V˙O2_{peak, est.}) by cycle ergometer test, and maternal circulating serum relaxin concentrations.

Results

Women with miscarriage displayed the highest level of absolute \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{V}{O}_2 $$\end{document}V˙O2_{peak, est.} (2.61 l/min) and the lowest serum relaxin concentrations (640 ng/l). Among women with spontaneous onset of labour, the mean absolute \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{V}{O}_2 $$\end{document}V˙O2_{peak, est.} increased successively from the lowest estimated oxygen uptake of 2.31 l/min among those with preterm birth (n = 28), to an oxygen uptake of 2.49 l/min among women with postterm birth (n = 31). An opposite trend was shown regarding serum relaxin concentrations from women with miscarriage to those with postterm birth. Serum relaxin concentrations, but not absolute \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{V}{O}_2 $$\end{document}V˙O2_{peak, est.} was significantly and independently associated with duration of gestation in women with miscarriages, and absolute \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{V}{O}_2 $$\end{document}V˙O2_{peak, est.}, age and multiple pregnancy were independently associated with duration of gestation in women with spontaneous onset of labour.

Conclusions

Physical fitness appears to be a protective factor of established pregnancies and not significantly involved in the risk of early miscarriage. Additional studies are needed to more clearly define the role of relaxin in miscarriage.