Diet, Physical Activity and Gestational Weight Gain Patterns among Pregnant Women Living with Obesity in the North East of England: The GLOWING Pilot Trial

The Gestational Obesity Weight Management: Implementation of National Guidelines (GLOWING) study: a pilot cluster randomised controlled trial

BACKGROUND

Pregnancy weight management interventions can improve maternal diet, physical activity, gestational weight gain, and postnatal weight retention. UK guidelines were published in 2010 but health professionals report multiple complex barriers to practice. GLOWING used social cognitive theory to address evidence-based barriers to midwives' implementation of weight management guidelines into routine practice. This paper reports the pilot trial outcomes relating to feasibility and acceptability of intervention delivery and trial procedures.

METHODS

GLOWING was a multi-centre parallel-group pilot cluster RCT comparing the delivery of a behaviour change intervention for midwives (delivered as training workshops) with usual practice. The clusters were four NHS Trusts in Northeast England, randomised to intervention or control arms. Blinding of allocation was not possible due to the nature of the intervention. We aimed to deliver the intervention to all eligible midwives in the intervention arm, in groups of 6 midwives per workshop, and to pilot questionnaire data collection for a future definitive trial. Intervention arm midwives' acceptability of GLOWING content and delivery was assessed using a mixed methods questionnaire, and pregnant women's acceptability of trial procedures by interviews. Quantitative data were analysed descriptively and qualitative data thematically.

RESULTS

In intervention arm Trusts, 100% of eligible midwives (n = 67) were recruited to, and received, the intervention; however, not all workshops had the planned number of attendees (range 3-8). The consent rate amongst midwives randomised (n = 100) to complete questionnaires was 74% (n = 74) (95% CI 65%, 83%), and overall completion rate 89% (n = 66) (95% CI 82%, 96%). Follow-up response rate was 66% (n = 49) (95% CI 55%, 77%), with a marked difference between intervention (39%, n = 15) and control (94%, n = 34) groups potentially due to the volume of research activities. Overall, 64% (n = 47) (95% CI 53%, 75%) completed both baseline and follow-up questionnaires. Midwives viewed the intervention as acceptable and directly relevant to routine practice. The least popular components related to scripted role-plays. Pregnant women viewed the recruitment and trial processes to be acceptable.

CONCLUSIONS

This rigorously conducted pilot study demonstrated feasibility intervention delivery and a high level of acceptability amongst participants. It has provided information required to refine the intervention and trial protocol, enhancing confidence that a definitive trial could be carried out.

TRIAL REGISTRATION

ISRCTN46869894; retrospectively registered 25th May 2016, www.isrctn.com/ISRCTN46869894 .

Addressing inequalities and improving maternal and infant outcomes: the potential power of nutritional interventions across the reproductive cycle

Maternal nutrition is essential for optimal health and well-being of women and their infants. This review aims to provide a critical overview of the evidence-base relating to maternal weight, obesity-related health inequalities and dietary interventions encompassing the reproductive cycle: preconception, pregnancy, postnatal and interpregnancy. We provide an overview of UK data showing that overweight and obesity affects half of UK pregnancies, with increased prevalence among more deprived and minoritised ethnic populations, and with significant health and cost implications. The existing intervention evidence-base primarily focuses on the pregnancy period, where extensive evidence demonstrates the power of interventions to improve maternal diet behaviours, and minimise gestational weight gain and postnatal weight retention. There is a lack of consistency in the intervention evidence-base relating to interventions improving pregnancy health outcomes, although there is evidence of the potential power of the Mediterranean and low glycaemic index diets in improving short- and long-term health of women and their infants. Postnatal interventions focus on weight loss, with some evidence of cost-effectiveness. There is an evidence gap for preconception and interpregnancy interventions. We conclude by identifying that interventions do not address cumulative maternal obesity inequalities and overly focus on individual behaviour change. There is a lack of a joined-up approach for interventions throughout the entire reproductive cycle, with a current focus on specific stages (i.e. pregnancy) in isolation. Moving forward, the potential power of nutritional interventions using a more holistic approach across the different reproductive stages is needed to maximise the benefits on health for women and children.

Maternal Obesity and Patterns in Postnatal Diet, Physical Activity and Weight among a Highly Deprived Population in the UK: The GLOWING Pilot Trial

Preconception obesity is associated with adverse pregnancy outcomes and deprivation. The postnatal period provides an opportunity for preconception intervention. There is a lack of published postnatal behaviour and weight data to inform intervention needs. Secondary analysis of the GLOWING study explored postnatal diet, physical activity (PA) and weight among women living with obesity in deprivation. Thirty-nine women completed food frequency and PA questionnaires and provided weight measurement(s) between 3-12 months postnatal. Women's diet and PA fell short of national guidelines, especially for fruit/vegetables (median 1.6-2.0 portions/day) and oily fish (0-4 g/day). PA was predominantly light intensity. Patterns in weight change across time points indicated postnatal weight loss compared with 1st (median -0.8 to -2.3 kg) and 3rd-trimester weights (-9.0 to -11.6 kg). Weight loss was higher among women without excessive gestational weight gain (GWG) (-2.7 to -9.7 kg) than those with excessive GWG (2.3 to -1.8 kg), resulting in postnatal weight measurements lower than their 1st trimester. These pilot data suggest preconception interventions should commence in pregnancy with a focus on GWG, and postnatal women need early support to achieve guideline-recommendations for diet and PA. Further research in a larger population could inform preconception intervention strategies to tackle inequalities in maternal obesity and subsequent pregnancy outcomes.

Midwives' survey of their weight management practice before and after the GLOWING guideline implementation intervention: A pilot cluster randomised controlled trial

BACKGROUND

Maternal weight management is a priority due to pregnancy risks for women and babies. Interventions significantly improve maternal diet, physical activity, weight, and pregnancy outcomes. There are complex barriers to midwives' implementation of guidelines; low self-efficacy is a core implementation barrier. The GLOWING intervention uses social cognitive theory (SCT) to address evidence-based barriers to practice. The intervention aimed to support midwives' implementation of guidelines.

METHODS

An external rehearsal pilot cluster randomised controlled trial in four NHS Trusts (clusters) in England, UK. Clusters were randomised to intervention (where all eligible midwives received the intervention) or control (no intervention delivered) arms. A random sample of 100 midwives were invited to complete questionnaires pre- and post-intervention. UK guideline recommendations relating to midwives' practice were categorised into: 1) communication-related behaviours (including weight- and risk-communication), and 2) support/intervention-related behaviours (including diet/nutrition, physical activity, weight management, referrals/signposting). Questionnaires were developed using SCT constructs (self-efficacy, outcome expectancies, intentions, behaviours) and 7-point Likert scale, converted to a 0-100 scale. Higher scores were more positive. Descriptive statistics compared intervention and control arms, pre- and post-intervention.

RESULTS

Seventy-four midwives consented and 68 returned questionnaires. Pre-intervention, self-efficacy for support/intervention-related behaviours scored lowest. In controls, there was limited difference between the pre- and post-intervention scores. Post-intervention, mean (SD) scores were consistently higher among intervention midwives than controls, particularly for support/intervention self-efficacy (71.4 (17.1) vs. 58.4 (20.1)). Mean (SD) self-efficacy was higher post-intervention than pre-intervention for all outcomes among intervention midwives, and consistently higher than controls. Mean differences pre- and post-intervention were greatest for support/intervention self-efficacy (17.92, 95% CI 7.78-28.07) and intentions (12.68, 95% CI 2.76-22.59). Self-efficacy was particularly increased for diet/nutrition and physical activity (MD 24.77, 95% CI 14.09-35.44) and weight management (18.88, 95% CI 7.88-29.88) behaviours, which showed the largest increase in scores.

CONCLUSIONS

This study supports the theoretical models used to develop GLOWING, where low self-efficacy was a core implementation barrier. Results suggest that GLOWING successfully targets self-efficacy, potentially with a positive impact on guideline implementation. A definitive trial is required to determine effectiveness.

TRIAL REGISTRATION

ISRCTN46869894, retrospectively registered 25/05/2016, http://isrctn.com/ISRCTN46869894.

Quality assessment of pre- and postnatal nutrition and exercise mobile applications in the United States and China

Background

Mobile applications (apps) are becoming increasingly prevalent as tools for improving maternal health behaviors. However, the recently updated content and quality of these apps remain unknown. This research investigated the fundamental characteristics, functional modules, and overall quality of maternal apps available in the United States and China to reveal critical nutrition and physical activity gaps.

Methods

A systematic search was performed in Android and iOS app stores (China and the United States). Apps were eligible if they targeted pregnant or postpartum women, focused on nutrition or physical activity, and had interfaces in English or Chinese. The basic characteristics, functional modules, and overall quality of the apps were evaluated, and differences between apps available in China or the United States were determined using analysis of variance and chi-square tests. Pearson correlations were utilized to investigate links between objective quality and user rating.

Results

A total of 65 maternity-related nutrition and physical activity apps (34 from China and 31 from the United States) were eligible. Among them, 68% (21/31) of US apps and 56% (19/34) of Chinese apps did not provide supporting evidence for their content. A greater number of Chinese apps provided app-based general education modules, namely food nutrition knowledge (n = 0, 0% in the United States vs. n = 30, 88.2% in China). Meanwhile, a greater number of US apps provided exercise modules, namely pregnancy yoga (n = 21, 67.7% in the United States vs. n = 2, 5.9% in China). The overall app quality rating in the United States was lower than it was in China (mean: 3.5, SD: 0.6 in China vs. mean: 3.4, SD: 0.7 in the United States). There was no relationship between the overall app quality rating and the user rating in either country (rho = 0.11 in China and rho = -0.13 in the United States).

Conclusion

The characteristics and functional modules of in-store apps for maternal nutrition and physical activity differed between the United States and China. Both countries' apps, especially Chinese apps, lacked evidence-based information, and there was no correlation between app quality and user rating. The results therefore suggest that user ratings cannot be used as an objective indicator of app quality and that it is necessary to improve the empirical basis and credibility of apps in both countries.

Subjective well-being, happiness, and environmental health factors related to women planning a pregnancy or pregnant, using mobile health intervention

Objectives

To compare the environmental health results in women trying to get pregnant or pregnant using a mobile health application (Green Page) through healthcare professionals or self-completed by women, and to explore the relationship between the subjective well-being of these women with their lifestyles and environmental factors.

Methods

A descriptive study with mixed methods was conducted in 2018. A mobile health survey was used in two phases. Phase 1 was a cross-sectional study through professionals (n  =  1100) followed by phase 2, a convenience sampling through women's self-reporting (n  =  3425). A personalized report was downloadable with health recommendations for the well-being of the mother and child.

Results

Of the 3205 participants (mean age  =  33 years, SD  =  0.2 years), 1840 were planning a pregnancy and 1365 were pregnant. One in five pregnant women had a low level of happiness. Globally, subjective well-being and happiness were found to be negatively associated with lack of contact with nature, sedentary lifestyle, excess weight, environmental exposure, and older age in pregnancy. Precisely 45%, 60%, and 14% of women were exposed to tobacco, alcohol, and illegal drugs, respectively. The women self-reported levels of risk factors higher than when the tool was used by or through professionals.

Conclusions

The use of mobile health interventions focused on environmental health during planning or pregnancy periods could help improve the quality of healthcare and foster greater involvement of women in their self-care process, thus promoting empowerment, healthier environments, and lifestyles. Ensuring equity of access and data protection are global challenges to be addressed.

Knowledge, attitude, and practice of the 2009 Institute of Medicine (IOM) recommendations on the nutritional management of diabetes in pregnancy: an online national survey

AIMS

As recommended by the Institute of Medicine (IOM), health practitioners should encourage a healthy nutrition and adequate weight gain during pregnancy in order to ensure favorable pregnancy and fetal outcomes, and to prevent diseases later in life for both mother and child. The purpose of this online survey was to determine the knowledge, attitude, and practice of the 2009 IOM recommendations among healthcare professionals managing nutritional therapy in pregnancies complicated by diabetes in Italy.

METHODS

A cross-sectional survey was conducted by using an online self-administered questionnaire undertaken between October and December 2021.

RESULTS

Of the 220 participants 89% were diabetologists/endocrinologists/internal medicine specialists and 11% dietitians/nutritionists. The survey found that the 53% of respondents provide a personalized diet to pregnant women with diabetes, while 32% a standard diet plan and only 15% healthy dietary advice. The 69% of the participants investigated for appropriate gestational weight gain, mainly based on pre-pregnancy BMI (96%), gestational weight gain (GWG) at first prenatal visit (80%) and presence of twin pregnancy (58%). Maternal weight gain was evaluated at each regularly scheduled prenatal visit and compared with IOM recommendations for the 87% of healthcare professionals. Diet plan was periodically re-evaluated and/or modified (90% of participants), based on inadequate maternal weight gain and/or fetal growth abnormalities (78%), trimester transition (53%), changes in physical activity and/or a "feel hungry" (50%).

CONCLUSIONS

This survey reported the knowledge and attitude of IOM guidelines and the nutritional knowledge and practice of Italian professionals on the nutritional management of diabetes in pregnancy. The application of these recommendations seemed more feasible in clinics/team dedicated to "Diabetes in Pregnancy".