Effects of a lifestyle intervention in routine care on prenatal physical activity - findings from the cluster-randomised GeliS trial

Physical activity promotion among pregnancy - the role of physician from the women's perspective

Objective

The clear benefits of planned and supervised physical activity (PA) during pregnancy make it imperative that women are encouraged and educated about this activity. This study aimed to investigate how effectively physician promote physical activity and exercise among pregnant women. It also examines pro-health changes in selected health behaviours during pregnancy.

Methods

This cross-sectional study recruited a total of 353 pregnant women in Wielkopolskie Voivodship in Poland. An anonymous survey (on-line or in-paper) was used to assess physical activity before and during pregnancy (with Pregnancy Physical Activity Questionnaire), physical activity self-efficacy, well-being (WHO-5 Well-Being Index), and guidance received from physicians on physical activity during pregnancy.

Results

Only 41% of women surveyed followed WHO recommendations for PA before pregnancy, and they were much more likely to discuss safety and the need to change the intensity or type of PA with their doctor or gynaecologist. Only 23% of women were asked about their PA before pregnancy and less than 40% were encouraged to be active during pregnancy. We observed a higher probability of poor well-being among pregnant women who were inactive before pregnancy (OR = 1.873, 95%CI 1.026 to 3.421, p = 0.041).

Conclusion

Health professionals infrequently educate and motivate women to be physically active during pregnancy. Physician advice, as it is currently perceived by women, seems to be insufficient to help pregnant women meet the recommendations for PA during pregnancy.

Development and validation of a screening questionnaire for early identification of pregnant women at risk for excessive gestational weight gain

BACKGROUND

Excessive weight gain during pregnancy is associated with adverse health outcomes for mother and child. Intervention strategies to prevent excessive gestational weight gain (GWG) should consider women's individual risk profile, however, no tool exists for identifying women at risk at an early stage. The aim of the present study was to develop and validate a screening questionnaire based on early risk factors for excessive GWG.

METHODS

The cohort from the German "Gesund leben in der Schwangerschaft"/ "healthy living in pregnancy" (GeliS) trial was used to derive a risk score predicting excessive GWG. Sociodemographics, anthropometrics, smoking behaviour and mental health status were collected before week 12^th of gestation. GWG was calculated using the last and the first weight measured during routine antenatal care. The data were randomly split into development and validation datasets with an 80:20 ratio. Using the development dataset, a multivariate logistic regression model with stepwise backward elimination was performed to identify salient risk factors associated with excessive GWG. The β coefficients of the variables were translated into a score. The risk score was validated by an internal cross-validation and externally with data from the FeLIPO study (GeliS pilot study). The area under the receiver operating characteristic curve (AUC ROC) was used to estimate the predictive power of the score.

RESULTS

1790 women were included in the analysis, of whom 45.6% showed excessive GWG. High pre-pregnancy body mass index, intermediate educational level, being born in a foreign country, primiparity, smoking, and signs of depressive disorder were associated with the risk of excessive GWG and included in the screening questionnaire. The developed score varied from 0-15 and divided the women´s risk for excessive GWG into low (0-5), moderate (6-10) and high (11-15). The cross-validation and the external validation yielded a moderate predictive power with an AUC of 0.709 and 0.738, respectively.

CONCLUSIONS

Our screening questionnaire is a simple and valid tool to identify pregnant women at risk for excessive GWG at an early stage. It could be used in routine care to provide targeted primary prevention measures to women at particular risk to gain excessive gestational weight.

TRIAL REGISTRATION

NCT01958307, ClinicalTrials.gov, retrospectively registered 9 October 2013.

Physical activity and pregnancy outcomes: an expert review

This expert review aimed to assess current literature on the effect and tracking of physical activity during pregnancy and associated outcomes. Self-reported physical activity may be inaccurate given the subjective nature of the questionnaires. The accelerometer ActiGraph is considered the "gold standard" to objectively measure physical activity. However, other more user-friendly wearable devices are now widely available and may accurately track physical activity. Conclusive data from both validated activity questionnaires and accelerometers indicate that physical activity is safe during pregnancy. In addition, studies of physical activity during pregnancy that evaluate pregnancy outcomes have found reduced risks of preterm birth, preeclampsia, and gestational diabetes mellitus and improved mental health among individuals who regularly engage in physical activity. In the United States, approximately 48% of pregnant individuals gain more than the recommended amount of weight during pregnancy; excessive gestational weight gain is associated with an increased risk of maternal and fetal complications, including preterm birth, preeclampsia, and gestational diabetes mellitus, and corresponding higher adverse short- and long-term maternal and offspring health outcomes. Although physical activity is safe during pregnancy and may reduce excessive gestational weight gain and resultant pregnancy complications, further research is needed to determine the frequency and duration of specific types of physical activity during pregnancy. Providers should encourage physical activity before and during pregnancy and educate patients regarding the benefits and safety of physical activity.

Impact of Physical Activity of Pregnant Women on Obstetric Outcomes

Regular and well-planned physical activity (PA) has a positive impact on pregnancy outcomes. In this study, we determine the impact of the PA of pregnant women on the occurrence of certain pregnancy outcomes, such as type of labor, duration of pregnancy, and birthweight. The study is based on the results of a Polish national survey performed between 2011 and 2017 on a group of 9170 women. The Pregnancy Physical Activity Questionnaire (PPAQ) was used to estimate the PA of pregnant women. Light intensity PA accounts for the largest proportion of women's total energy expenditure. Increase in women's total energy expenditure was associated with an increase in the birthweight of a child. A similar relationship was observed in the case of light and moderate PA. Vaginal birth was more common among women with higher total energy expenditure. Mothers of preterm children showed lower energy expenditure for each type of PA compared to term pregnancies. There was also a correlation between moderate and vigorous PA and low birthweight. Our study indicates that PA undertaken by pregnant women has a positive impact on pregnancy outcomes.

Are pre- and early pregnancy lifestyle factors associated with the risk of preterm birth? A secondary cohort analysis of the cluster-randomised GeliS trial

Background

Maternal lifestyle is discussed as a modifiable determinant in the prevention of preterm birth. However, previous research on associations between individual lifestyle factors and preterm birth risk is inconclusive. In this secondary analysis, we investigated the associations between several modifiable antenatal lifestyle factors and the odds of preterm birth.

Methods

This secondary cohort analysis used data from the cluster-randomised controlled “healthy living in pregnancy” (GeliS) trial. Data were collected from early pregnancy to birth with maternity records, validated questionnaires and birth protocols. Women with complete datasets for all covariates were eligible for analysis. Multivariate logistic regression models, adjusted for recognised risk factors, were fitted to determine whether dietary quality, assessed with a healthy eating index (HEI), physical activity (PA) levels and antenatal anxiety/distress influenced the odds of preterm birth. Moreover, the combined association between pre-pregnancy body mass index (BMI) and HEI on the odds of preterm birth was explored. The independent associations of individual dietary components and types of PA on prematurity were assessed by adjusted logistic regression models.

Results

Overall, 1738 women were included in the analysis. A low HEI significantly increased the odds of preterm birth (OR 1.54 (CI 1.04 – 2.30), p = 0.033), while no associations with either low PA levels or antenatal anxiety/distress were observed. BMI significantly interacted with HEI on the association with prematurity (p = 0.036). Energy % from protein and the intake of average portions of vegetables and cereals were significantly negatively associated with the odds of preterm birth. There was no significant evidence of an association between different types of PA and prematurity.

Conclusions

This cohort analysis revealed that low dietary quality in early pregnancy may increase the chance of giving birth prematurely, while healthier dietary choices may help to prevent preterm birth. More research on pre- and early pregnancy modifiable lifestyle factors is warranted.

Trial registration

This trial is registered with the Clinical Trial Registry ClinicalTrials.gov (NCT01958307). Registration date 09 October 2013, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04513-5.

Child Anthropometrics and Neurodevelopment at 2 and 3 Years of Age Following an Antenatal Lifestyle Intervention in Routine Care-A Secondary Analysis from the Cluster-Randomised GeliS Trial

Maternal characteristics around pregnancy may influence obesity risk and neurodevelopment in children. To date, the effect of antenatal lifestyle interventions on long-term child development is unclear. The objective was to investigate the potential long-term effects of an antenatal lifestyle intervention programme conducted alongside routine care on child anthropometrics and neurodevelopment up to 3 years of age. Mother-child pairs from the cluster-randomised GeliS trial were followed up to 3 years of age. Data on child anthropometrics in both groups were collected from routine health examinations. Neurodevelopment was assessed via questionnaire. Of the 2286 study participants, 1644 mother-child pairs were included in the analysis. Children from the intervention group were less likely to score below the cut-off in Fine motor (p = 0.002), and more likely to have a score below the cut-off in Problem-solving (p < 0.001) compared to the control group at 3 years of age. Mean weight, height, head circumference, body mass index, and the respective z-scores and percentiles were comparable between the groups at 2 and 3 years of age. We found no evidence that the lifestyle intervention affected offspring development up to 3 years of age. Further innovative intervention approaches are required to improve child health in the long-term.

How does antenatal lifestyle affect the risk for gestational diabetes mellitus? A secondary cohort analysis from the GeliS trial

OBJECTIVES

We aimed to investigate the predictive potential of early pregnancy factors such as lifestyle, gestational weight gain (GWG) and mental well-being on gestational diabetes mellitus (GDM) beyond established risk factors.

METHODS

GDM risk was investigated in the cohort of the German 'Gesund leben in der Schwangerschaft'/healthy living in pregnancy study. Women were recruited up to the 12th week of gestation. GDM was diagnosed with a 75 g oral glucose tolerance test between the 24th and 28th weeks of gestation. Pre-pregnancy age and weight, mental health and lifestyle were assessed via questionnaires. Maternal weight was measured throughout pregnancy. Early excessive GWG was defined based on the guidelines of the Institute of Medicine. The association between several factors and the odds of developing GDM was assessed using multiple logistic regression analyses.

RESULTS

Of 1694 included women, 10.8% developed GDM. The odds increased with pre-pregnancy BMI and age (women with obesity: 4.91, CI 3.35-7.19, p < 0.001; women aged 36-43 years: 2.84, CI 1.45-5.56, p = 0.002). Early excessive GWG, mental health and general lifestyle ratings were no significant risk factors. A 31% reduction in the odds of GDM was observed when <30% of energy was consumed from fat (OR 0.69, CI 0.49-0.96, p = 0.026). Vigorous physical activity tended to lower the odds without evidence of statistical significance (OR 0.59 per 10 MET-h/week, p = 0.076).

CONCLUSIONS

Maternal age and BMI stand out as the most important drivers of GDM. Early pregnancy factors like dietary fat content seem to be associated with GDM risk. Further evaluation is warranted before providing reliable recommendations.

Effects of a Prenatal Lifestyle Intervention in Routine Care on Maternal Health Behaviour in the First Year Postpartum-Secondary Findings of the Cluster-Randomised GeliS Trial

Lifestyle interventions during pregnancy were shown to beneficially influence maternal dietary behaviour and physical activity, but their effect on health behaviour after delivery is unclear. The objective of this secondary analysis was to investigate the sustained effect of a lifestyle intervention in routine care on maternal health behaviour during the first year postpartum. The cluster-randomised controlled "Healthy living in pregnancy" (GeliS) study included 2286 pregnant women. Data on maternal health behaviour were collected at 6-8 weeks (T1pp) and one year postpartum (T2pp) using validated questionnaires. The intervention group showed a lower mean intake of fast food (T1pp: p = 0.016; T2pp: p < 0.001) and soft drinks (T1pp: p < 0.001), a higher mean intake of vegetables (T2pp: p = 0.015) and was more likely to use healthy oils for meal preparation than the control group. Dietary quality rated by a healthy eating index was higher in the intervention group (T1pp: p = 0.093; T2pp: p = 0.043). There were minor trends towards an intervention effect on physical activity behaviour. The proportion of smokers was lower in the intervention group (p < 0.001, both time points). The lifestyle intervention within routine care modestly improved maternal postpartum dietary and smoking behaviours.

Infant growth during the first year of life following a pregnancy lifestyle intervention in routine care-Findings from the cluster-randomised GeliS trial

BACKGROUND

Lifestyle interventions in pregnancy may influence postpartum development and obesity risk in offspring. The impact of lifestyle interventions as health system-based approaches is unclear.

OBJECTIVE

To evaluate the effect of an antenatal lifestyle intervention conducted as public health approach on infant development and feeding practices.

METHODS

We followed offspring born to women participating in the cluster-randomised GeliS trial who received usual care (CG) or repeated lifestyle counselling (IG). We collected data on offspring development and complementary feeding until the 12^th month postpartum.

RESULTS

Of the 1998 mother-child pairs, 1783 completed the follow-up. Mean infant weight at 12 months was comparable between groups (IG: 9497.9 ± 1137.0 g; CG: 9433.4 ± 1055.2 g; P = .177). There was no significant evidence of differences in sex- and age-adjusted z-scores or in the odds of offspring being overweight. More infants in the IG received whole-grain products compared to the CG (95.6% vs. 90.8%; P = .003). Despite small differences in the timing of introducing solid foods, there were no further significant differences in the pattern of complementary feeding.

CONCLUSIONS

The antenatal lifestyle intervention embedded in routine care did not substantially influence infant anthropometrics and is thus unlikely to impact future development.

Associations between lifestyle interventions during pregnancy and childhood weight and growth: a systematic review and meta-analysis

BACKGROUND

Maternal health and lifestyle during pregnancy may be critical for the onset and progression of childhood obesity. Prenatal lifestyle interventions have been shown to positively affect maternal behaviors, gestational weight gain, and anthropometric outcomes in infants at birth. The influence of such interventions on child weight or growth beyond birth is unknown. We therefore examined the association between lifestyle interventions during pregnancy and anthropometric outcomes during childhood.

METHODS

A systematic literature search was conducted in three electronic databases, two clinical trial registers and further sources, without language or publication status restrictions. Additionally, 110 study authors were contacted to obtain unpublished data. Randomized controlled trials comparing any antenatal lifestyle or behavioral intervention to standard prenatal care, in women of any body mass index (BMI), with offspring anthropometric data at 1 month of age or older, were considered. Two reviewers independently extracted data and assessed the risk of bias using the Cochrane Collaboration's updated tool. Data on weight, length, and BMI, and corresponding z-scores, were stratified into six age ranges and weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated in univariate and multivariate random-effects meta-analytical models.

RESULTS

Twenty trials comprising 11,385 women were included in this systematic review, of which 19 were combined in meta-analyses. Overall, lifestyle interventions during pregnancy were not associated with differences in weight, length, BMI, or corresponding z-scores, in children aged 1 month to 7 years (e.g. weight in 5 to 6 month old children, WMD: 0.02 kg; 95% CI: - 0.05 to 0.10 kg, I2 = 38%; 13 studies, 6667 participants). Findings remained consistent when studies were stratified by maternal baseline BMI or other risk factors, and intervention content and duration. Based on the GRADE criteria, the strength of the body of evidence was considered moderate.

CONCLUSION

Prenatal lifestyle interventions were not shown to influence childhood weight or growth. Nevertheless, women should be encouraged to pursue a healthy lifestyle during pregnancy. Further efforts to establish early prevention strategies for childhood obesity are urgently needed. Thus, large, high-quality studies with pre-planned, long-term follow-ups are warranted.

TRIAL REGISTRATION

PROSPERO CRD42018118678 .

Evaluation of antenatal risk factors for postpartum depression: a secondary cohort analysis of the cluster-randomised GeliS trial

BACKGROUND

Maternal weight variables are important predictors of postpartum depression (PPD). While preliminary evidence points to an association between pre-pregnancy obesity and PPD, the role of excessive gestational weight gain (GWG) on PPD is less studied. In this secondary cohort analysis of the German 'healthy living in pregnancy' (GeliS) trial, we aimed to investigate associations between weight-related variables and PPD and to assess the influence of GWG on the risk for PPD.

METHODS

We included women with normal weight, overweight, and obesity (BMI 18.5-40.0 kg/m²). Symptoms of PPD were assessed 6-8 weeks postpartum using the Edinburgh Postnatal Depression Scale. Pre-pregnancy BMI was self-reported. During the course of pregnancy, weight was measured at gynaecological practices within regular check-ups. GWG was defined as the difference between the last measured weight before delivery and the first measured weight at the time of recruitment (≤ 12^th week of gestation). Excessive GWG was classified according to the Institute of Medicine. Multiple logistic regression analyses were used to estimate the odds of PPD in relation to pre-pregnancy BMI, GWG, and excessive GWG adjusting for important confounders.

RESULTS

Of the total 1583 participants, 45.6% (n = 722) showed excessive GWG and 7.9% (n = 138) experienced PPD. Pre-pregnancy BMI (per 5-unit increase; OR = 1.23, 95% CI 1.08-1.41, p = 0.002) and pre-pregnancy overweight or obesity were significantly positively associated with the odds of developing PPD, particularly among women with an antenatal history of anxiety or depressive symptoms (overweight: OR = 1.93, 95% CI = 1.15-3.22, p = 0.01; obesity: OR = 2.11, 95% CI = 1.13-3.96, p = 0.02). Sociodemographic or lifestyle factors did not additively influence the odds of having PPD. In fully adjusted models, there was no significant evidence that GWG or the occurrence of excessive GWG increased the odds of experiencing PPD (excessive vs. non-excessive: OR = 3.48, 95% CI 0.35-34.94; GWG per 1 kg increase: OR = 1.16, 95% CI 0.94-1.44).

CONCLUSION

Pre-pregnancy overweight or obesity is associated with PPD independent of concurrent risk factors. History of anxiety or depressive symptoms suggests a stress-induced link between pre-pregnancy weight and PPD.

TRIAL REGISTRATION

NCT01958307 , ClinicalTrials.gov, retrospectively registered on 9 October 2013.

Correction To: Effects of a lifestyle intervention in routine care on prenatal physical activity - findings from the cluster-randomised GeliS trial

Following publication of the original article [1], the author notified us about incorrectly formatted of Table 2 and Table 3.

Associations between the Prenatal Diet and Neonatal Outcomes-A Secondary Analysis of the Cluster-Randomised GeliS Trial

The prenatal lifestyle, including maternal dietary behaviour, is an important determinant of offspring health. This secondary cohort analysis of the GeliS ("healthy living in pregnancy") trial investigated associations between antenatal dietary factors and neonatal weight parameters. The cluster-randomised GeliS trial included 2286 pregnant women. Dietary information was collected with food frequency questionnaires before or in the 12th (T0) and after the 29th week of gestation (T1). Consumption of vegetables (41.28 g per portion at T0, p = 0.001; 36.67 g per portion at T1, p = 0.001), fruit (15.25 g per portion at T1, p = 0.010) and dietary quality, measured with a Healthy Eating Index (39.26 g per 10 points at T0, p = 0.004; 42.76 g per 10 points at T1, p = 0.002) were positively associated with birth weight. In contrast, sugar-sweetened beverages (10.90 g per portion at T0, p = 0.003; 8.19 g per portion at T1, p = 0.047), higher sugar consumption at T0 (8.27 g per 10 g, p = 0.032) and early pregnancy alcohol intake (15.32 g per g, p = 0.039) were inversely associated with birth weight. Most other dietary factors were not associated with neonatal weight. Some components reflecting a healthy maternal diet were associated with a modest increase in offspring birth weight, whereas some unhealthy components slightly reduced neonatal weight.

Effects of a Lifestyle Intervention in Routine Care on Short- and Long-Term Maternal Weight Retention and Breastfeeding Behavior-12 Months Follow-up of the Cluster-Randomized GeliS Trial

Postpartum weight retention (PPWR) is associated with an increased risk for maternal obesity and is discussed to be influenced by breastfeeding. The objective was to evaluate the effect of a lifestyle intervention delivered three times during pregnancy and once in the postpartum period on PPWR and on maternal breastfeeding behavior. In total, 1998 participants of the cluster-randomized "healthy living in pregnancy" (GeliS) trial were followed up until the 12th month postpartum (T2pp). Data were collected using maternity records and questionnaires. Data on breastfeeding behavior were collected at T2pp. At T2pp, mean PPWR was lower in women receiving counseling (IV) compared to the control group (C) (-0.2 ± 4.8 kg vs. 0.6 ± 5.2 kg), but there was no significant evidence of between-group differences (adjusted p = 0.123). In the IV, women lost more weight from delivery until T2pp compared to the C (adjusted p = 0.008) and showed a slightly higher rate of exclusive breastfeeding (IV: 87.4%; C: 84.4%; adjusted p < 0.001). In conclusion, we found evidence for slight improvements of maternal postpartum weight characteristics and the rate of exclusive breastfeeding in women receiving a lifestyle intervention embedded in routine care, although the clinical meaning of these findings is unclear.