Intervention Strategies to Address Barriers and Facilitators to a Healthy Lifestyle Using the Behaviour Change Wheel: A Qualitative Analysis of the Perspectives of Postpartum Women

Postpartum women experience unique barriers to maintaining healthy lifestyles after birth. Theory-based behaviour change techniques and intervention strategies can be integrated into postpartum lifestyle interventions to enable women to overcome barriers to change. This study aims to explore barriers and facilitators to engaging in healthy postpartum lifestyle behaviours and develop intervention strategies for integration in a postpartum lifestyle intervention using the Behaviour Change Wheel (BCW). Semi-structured interviews were conducted with women up to two years postpartum (n = 21). Interviews were thematically analysed, themes were mapped to the Capability, Opportunity, and Motivation Model of Behaviour Change and intervention strategies were developed using the BCW. Findings suggest that women face barriers and facilitators within capability (sleep deprivation, mental exhaustion, ability to plan), opportunity (support of friends, partners and extended families) and motivation (challenges with prioritising self, exercise to cope with stress). Intervention strategies included supporting behaviour regulation and sleep to enhance capability, engaging partners, strengthening peer support to create opportunities and highlighting the mental health benefits of healthy lifestyles to inspire motivation. Integrating targeted evidence-based behaviour change strategies into postpartum lifestyle interventions may support women in overcoming commonly reported barriers to a healthy lifestyle.

Co-designing a community lifestyle intervention program to reduce postpartum weight retention

BACKGROUND

Postpartum weight retention is a major contributor to obesity in later life resulting in long-term health consequences in women. Postpartum lifestyle interventions are known to be effective in reducing postpartum weight retention and improving the overall health and wellbeing of mothers but have poor reach and engagement. This study describes the engagement of mothers with young children in the development of a theory- and evidence-based intervention to reduce postpartum weight retention.

METHODS

A participatory design methodology with input from a community mothers' group, literature reviews and an expert advisory group was applied. Mothers who were members of 'Mothers of Preschoolers' (MOPS) were invited to participate in a focus group discussion and two co-design workshop sessions.

RESULTS

Thirteen women participated in a focus group discussion and 12 women in each co-design workshop. We found that mothers valued having social support from their peers, practical support such as meal delivery, and learning opportunities that focus on the mother's health and wellbeing. The advisory group suggested leveraging the unique skills and prior experiences of mothers within the group and developing a curriculum that mothers can be trained to deliver.

CONCLUSION

A program that emphasizes the strengths and value of mothers can increase their self-worth and self-confidence resulting in intrinsic motivation to improve lifestyle behaviours. An intervention designed to be implemented by MOPS for its members and incorporated into their regular sessions has the potential for feasibility and acceptability among mothers with young children.

PATIENT OR PUBLIC CONTRIBUTION

Mothers with young children were part of the program planners and were involved in the design and conduct of this study and in the interpretation of the findings. A member of a community mothers' group recruited other mothers with young children within the group to participate in a series of sessions to discuss their experiences of the postpartum period and preferences for a lifestyle program. The mothers identified the behavioural outcomes and program goals for a postpartum lifestyle program and then generated the program ideas based on these.

Assessing the influence of preconception diet on female fertility: a systematic scoping review of observational studies

BACKGROUND

Preconception diet is a proposed modifiable risk factor for infertility. However, there is no official guidance for women in the preconception period as to which dietary approaches may improve fertility.

OBJECTIVE AND RATIONALE

A comprehensive synthesis of the relevant evidence is key to determine the potentially effective dietary patterns and components as well as evidence gaps, and to provide information for nutritional recommendations for couples planning a pregnancy.

SEARCH METHODS

In this systematic scoping review, four electronic databases (Medline and EMBASE via Ovid processing, CAB Direct, and CINAHL via EBSCO) were searched for observational studies (prospective and retrospective cohort, cross-sectional, and case-control studies) from inception to 27 September 2021. Eligible studies included women of reproductive age during the preconception period, and evaluated exposures related to preconception diet and outcomes related to fertility. Results were synthesized using a descriptive approach.

OUTCOMES

A total of 36 studies were eligible for inclusion (31 prospective, 3 cross-sectional, and 2 case-control studies) and were published between 2007 and 2022. Of the assessed dietary exposures, increased adherence to the Mediterranean diet displayed the strongest and most consistent association with improved clinical pregnancy rates. Reducing trans fatty acids (TFAs), saturated fatty acids, and discretionary food intake (fast food and sugar-sweetened beverages) were associated with improvements in live birth, clinical pregnancy rates, and related ART outcomes. The dietary components of seafood, dairy, and soy demonstrated inconsistent findings across the few included studies.

WIDER IMPLICATIONS

Due to heterogeneity and the limited available literature on most exposures, there is insufficient evidence to support any specific dietary approach for improving fertility. However, following some of the dietary approaches outlined in this review (anti-inflammatory diets, reducing TFA, and discretionary food intake) are consistent with broad healthy eating guidelines, have little to no associated risk, and offer a plausible set of possible benefits. This warrants further exploration in randomized controlled trials.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

STUDY QUESTION

What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

WHAT IS KNOWN ALREADY

The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist.

STUDY DESIGN, SIZE, DURATION

The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout.

PARTICIPANTS/ MATERIALS, SETTING, METHODS

This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC).

MAIN RESULTS AND THE ROLE OF CHANCE

The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall, recommendations are strengthened and evidence is improved, but remain generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

WIDER IMPLICATIONS OF THE FINDINGS

The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation programme supports the Guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and the Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the sponsoring organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.

Externally validated prediction models for pre-eclampsia: systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the performance of existing externally validated prediction models for pre-eclampsia (specifically for any- early- late-onset and preterm pre-eclampsia).

METHODS

A systematic search was conducted in five databases (MEDLINE, Embase, Emcare, CINAHL, and Maternity and Infant Care Database) to identify studies based on Population, Index model, Comparator, Outcome, Timing, and Setting (PICOTS) approach until May 20, 2023. We extracted data using the CHARMS checklist and appraised risk of bias using PROBAST tool. Discrimination and calibration performance were meta-analysed when appropriate.

RESULTS

Twenty-three publications reported 52 externally validated prediction models on pre-eclampsia (twenty any-onset, seventeen early-onset, fourteen late-onset, and one preterm pre-eclampsia). No model had the same set of predictors. Fifteen, two, and three any-onset pre-eclampsia models were externally validated once, twice, and thrice, respectively, and the Fetal Medicine Foundation (FMF) preterm model was widely validated in sixteen different settings. The most common predictors were maternal characteristics (pre-pregnancy BMI, prior pre-eclampsia, family history of pre-eclampsia, chronic medical conditions, and ethnicity) and biomarkers (uterine artery pulsatility index and pregnancy-associated plasma protein-A). The model for preterm pre-eclampsia (triple test FMF) had the best performances with a pooled area under the receiver operating characteristics curve (AUROC) of 0.90 (95% prediction interval (PI) 0.76 - 0.96) and was well-calibrated. The other models generally had poor to fair discrimination performance (AUROC median 0.66, range 0.53 to 0.77) and were overfitted in calibration after external validation. Apart from the FMF model, only the two most validated models in any-onset pre-eclampsia using isolated maternal characteristics, produced reasonable pooled AUROCs of 0.71 (95% PI 0.66 - 0.76) and 0.73 (0.55 - 0.86).

CONCLUSION

Existing externally validated prediction models for any-, early-, and late-onset pre-eclampsia have limited discrimination and calibration performance with inconsistent input variables. The triple test FMF model had excellent discrimination performance in predicting preterm pre-eclampsia in numerous settings, but the inclusion of specialised biomarkers may limit feasibility and implementation outside of high-resource settings. This article is protected by copyright. All rights reserved.

Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

STUDY QUESTION

What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

WHAT IS KNOWN ALREADY

The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist.

STUDY DESIGN, SIZE, DURATION

The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC).

MAIN RESULTS AND THE ROLE OF CHANCE

The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall, recommendations are strengthened and evidence is improved, but remain generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

WIDER IMPLICATIONS OF THE FINDINGS

The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation programme supports the Guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and the European Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the sponsoring organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome†

STUDY QUESTION

What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

WHAT IS KNOWN ALREADY

The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist.

STUDY DESIGN, SIZE, DURATION

The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations, with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC).

MAIN RESULTS AND THE ROLE OF CHANCE

The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall, recommendations are strengthened and evidence is improved, but remains generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

WIDER IMPLICATIONS OF THE FINDINGS

The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the Guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and European Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the partnering organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.

Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome

STUDY QUESTION

What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

WHAT IS KNOWN ALREADY

The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from 6 continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low- to low-quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus-based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, the evidence quality was low, and evidence-practice gaps persist.

STUDY DESIGN, SIZE, AND DURATION

The 2023 International Evidence-based Guideline update re-engaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation, and ultimately recommendation strength, and diversity and inclusion were considered throughout.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

This summary should be read in conjunction with the full guideline for detailed participants and methods. Governance included a 6-continent international advisory and management committee, 5 guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health, and other experts, alongside consumers, project management, evidence synthesis, statisticians, and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and 5 face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across 5 guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council.

MAIN RESULTS AND THE ROLE OF CHANCE

The evidence in the assessment and management of PCOS has generally improved in the past 5 years but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include the following: (1) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm, and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only; (2) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnoea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; (3) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care, and shared decision-making to improve patient experience, alongside greater research; (4) maintained emphasis on healthy lifestyle, emotional well-being, and quality of life, with awareness and consideration of weight stigma; and (5) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

LIMITATIONS AND REASONS FOR CAUTION

Overall, recommendations are strengthened and evidence is improved but remains generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

WIDER IMPLICATIONS OF THE FINDINGS

The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input, and consumer preferences. Research recommendations have been generated, and a comprehensive multifaceted dissemination and translation programme supports the guideline with an integrated evaluation programme.

Impact of COVID-19 Restriction on Weight, Physical Activity, Diet and Psychological Distress on People with PCOS

BACKGROUND

People with polycystic ovary syndrome (PCOS) have higher weight gain and psychological distress compared to those without PCOS. While COVID-19 restrictions led to population level adverse changes in lifestyle, weight gain and psychological distress, their impact on people with PCOS is unclear. The aim of this study was to investigate the impact the 2020 COVID-19 restrictions had on weight, physical activity, diet and psychological distress for Australians with PCOS.

METHODS

Australian reproductive-aged women participated in an online survey with assessment of weight, physical activity, diet and psychological distress. Multivariable logistic and linear regression were used to examine associations between PCOS and residential location with health outcomes.

RESULTS

On adjusted analysis, those with PCOS gained more weight (2.9%; 95% CI; 0.027-3.020; p = 0.046), were less likely to meet physical activity recommendations (OR 0.50; 95% CI; 0.32-0.79; p = 0.003) and had higher sugar-sweetened beverage intake (OR 1.74; 95% CI 1.10-2.75; p = 0.019) but no differences in psychological distress compared to women without PCOS.

CONCLUSIONS

People with PCOS were more adversely affected by COVID-19 restrictions, which may worsen their clinical features and disease burden. Additional health care support may be necessary to assist people with PCOS to meet dietary and physical activity recommendations.

Can Dietary Patterns Impact Fertility Outcomes? A Systematic Review and Meta-Analysis

There are conflicting results on the effect of diet on fertility. This study aimed to assess the effect of different dietary patterns on fertility outcomes in populations who conceive spontaneously and those requiring assisted reproductive technology (ART). A systematic search and meta-analysis were performed for studies investigating dietary patterns or whole diets in reproductive aged women requiring ART or conceived naturally. Outcomes were live births, pregnancy rates and infertility rates. In amount of 15,396 studies were screened with 11 eligible studies. Ten different diet patterns were grouped broadly into categories: Mediterranean, Healthy or Unhealthy. For the Mediterranean diet, on excluding high risk-of-bias studies (n = 3), higher adherence was associated with improved live birth/pregnancy rates in ART [OR 1.91 (95% CI 1.14-3.19, I² 43%)] (n = 2). Adherence to various Healthy diets was associated with improved ART outcomes (ProFertility diet and Dutch Dietary Guidelines) and natural conception outcomes (Fertility diet). However, due to the variability in Healthy diets' components, results were not pooled. Studies demonstrated preliminary evidence for the role of dietary patterns or whole diets in improving pregnancy and live birth rates. However, due to heterogeneity across the literature it is currently unclear which diet patterns are associated with improvements in fertility and ART outcomes.

Modelling the impact of diet and physical activity on body mass index in pre-pregnant and postpartum women

OBJECTIVES

This study aimed to assess, using simulation modeling, the theoretical effect of key diet and physical activity (PA) modification scenarios could have on body mass index (BMI) in prepregnant and postpartum women.

METHODS

Simulation modeling using data from the 2011 to 2012 National Nutrition and Physical Activity Survey was performed for a subsample of prepregnant and postpartum women. The regression coefficients for each diet and PA component from multivariable linear regression equations for BMI were used to calculate a predicted BMI. Scenario modeling using a moderation approach was applied to targeted diet and PA components for the entire sample and subgroups of populations of women who failed to meet dietary and PA recommendations and among the lowest socioeconomic groups.

RESULTS

In prepregnancy and postpartum scenarios, respectively, increasing whole grains by 2 to 3 servings/d reduced BMI by 1.16 and 0.85 kg/m². For postpartum women, BMI was reduced by 0.28 kg/m² for every 5-g/d increase in fiber intake. A 480- and 540-min/wk increase in PA resulted in average BMI reductions of 0.95 and 1.19 kg/m² in prepregnant and postpartum women, respectively. A similar pattern of theoretical reductions in BMI was observed with increased whole grains, fiber, and PA among the most disadvantaged socioeconomic groups of women.

CONCLUSIONS

Increasing intake of whole grains by 2 to 3 servings/d could result in reductions in BMI of 1.16 and 0.85 kg/m², and a 480- and 540-min/wk increase in PA could result in BMI reduction of 0.95 and 1.19 kg/m² in prepregnant and postpartum women, respectively. This provides an evidence base to guide tailored nutrition messaging for obesity prevention efforts in reproductive age women.

Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

Levels of physical activity and sitting time in women with infants, toddlers and preschoolers: a population-based cross-sectional study

OBJECTIVES

Insufficient physical activity (PA) and prolonged sitting time (ST) increase the risk of chronic disease and mortality. Caring for young children can potentially impact maternal PA and sedentary behaviours. The aims of this study were to explore the levels of PA and ST in women with young children (infants, toddlers and preschoolers) and sociodemographic and behavioural factors associated with these.

STUDY DESIGN

This was a population-based cross-sectional study.

METHODS

Survey 5 data collected in 2009 (n = 4290) of the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health were used. Multiple linear and logistic regression models were used to examine associations.

RESULTS

In adjusted models, compared with women with preschoolers, women whose youngest child was an infant aged 0-6 months, aged >6-12 months or toddler had lower PA (-321.3 MET.min/week [95% confidence interval (CI) -416.2, -226.4], -147.9 MET.min/week [95% CI -237.6, -58.1] and -106.4 MET.min/week [95% CI -172.3, -40.5]). ST was higher in women whose youngest child was an infant aged 0-6 months (0.48 h/day; 95% CI 0.19, 0.77) but lower with infants aged >6-12 months (-0.33 h/day; 95% CI -0.60, -0.05) and toddlers (-0.40 h/day; 95% CI -0.60, -0.20) than in those with preschoolers. The findings were similar in the logistic model. Sociodemographic and behavioural factors such as occupation and marital status also influenced PA and ST.

CONCLUSIONS

Women with infants and toddlers have lower PA than women with preschoolers. Women are more likely to sit more in the first 6 months after childbirth. These findings can inform resources and intervention development to improve activity levels in women with young children through consideration of the age of the youngest child, sociodemographic and behavioural factors.

Better care for women with polycystic ovary syndrome - a proposal for an international evidence based best practice framework to improve care

PURPOSE OF REVIEW

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive-age women and has reproductive, pregnancy, metabolic, dermatologic, and psychologic complications. Here we summarize current challenges and gaps in PCOS care, and propose a pathway forward to implement high quality international guideline recommendations and resources, through development of a best practice framework and benchmarking for evidence-based, patient-centric models of care (MoC).

RECENT FINDINGS

The majority of women with PCOS are unsatisfied with their healthcare experience due to delayed diagnosis, inadequate information provision and inconsistent advice from diverse healthcare providers. The 2018 International Evidence-based PCOS Guideline recommended co-development of evidence-based, patient centric MoC. High-quality guidelines and resources are now available to help women understand and manage PCOS and to assist healthcare professionals to partner in their care. Leveraging these and developing a best practice framework for patient centric PCOS MoC is now a vital to optimise care and outcomes in this common and neglected condition.

SUMMARY

Collaborative interdisciplinary efforts from academic leads, healthcare professionals and consumers are now needed to co-develop a framework and benchmarking performance indicators to guide evidence-based, patient centric PCOS MOC to improve experience and outcomes.

Dietary and/or physical activity interventions in women with overweight or obesity prior to fertility treatment: protocol for a systematic review and individual participant data meta-analysis

INTRODUCTION

Dietary and/or physical activity interventions are often recommended for women with overweight or obesity as the first step prior to fertility treatment. However, randomised controlled trials (RCTs) so far have shown inconsistent results. Therefore, we propose this individual participant data meta-analysis (IPDMA) to evaluate the effectiveness and safety of dietary and/or physical activity interventions in women with infertility and overweight or obesity on reproductive, maternal and perinatal outcomes and to explore if there are subgroup(s) of women who benefit from each specific intervention or their combination (treatment-covariate interactions).

METHODS AND ANALYSIS

We will include RCTs with dietary and/or physical activity interventions as core interventions prior to fertility treatment in women with infertility and overweight or obesity. The primary outcome will be live birth. We will search MEDLINE, Embase, Cochrane Central Register of Controlled Trials and trial registries to identify eligible studies. We will approach authors of eligible trials to contribute individual participant data (IPD). We will perform risk of bias assessments according to the Risk of Bias 2 tool and a random-effects IPDMA. We will then explore treatment-covariate interactions for important participant-level characteristics.

ETHICS AND DISSEMINATION

Formal ethical approval for the project (Venus-IPD) was exempted by the medical ethics committee of the University Medical Center Groningen (METc code: 2021/563, date: 17 November 2021). Data transfer agreement will be obtained from each participating institute/hospital. Outcomes will be disseminated internationally through the collaborative group, conference presentations and peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42021266201.

Comparison of dietary and physical activity behaviors in women with and without polycystic ovary syndrome: a systematic review and meta-analysis of 39 471 women

BACKGROUND

Lifestyle (dietary and/or physical activity [PA]) modification is recommended as first-line therapy to manage polycystic ovary syndrome (PCOS). Current recommendations are based on healthy lifestyle practices for the general public since evidence for unique lifestyle approaches in PCOS is limited and low quality.

OBJECTIVE AND RATIONALE

We aimed to synthesize evidence on dietary and PA behaviors between women with PCOS and those without PCOS. Primary outcomes were overall diet quality, total energy intake and total PA, and secondary outcomes included macronutrients, micronutrients, food groups, foods, glycemic indices, sedentary time and sitting levels. We conducted this work to identify any unique lifestyle behaviors in women with PCOS that could underlie the propensity of weight gain and obesity in PCOS and be targeted for precision nutrition and PA interventions. These findings could be used to inform future practice recommendations and research that more effectively address complications (weight gain, obesity, diabetes, infertility, cardiovascular disease and mental health) in this high-risk population.

SEARCH METHODS

Databases of MEDLINE, Web of Science, Scopus and CINAHL were searched until 15 February 2022 to identify observational studies documenting dietary and PA behaviors between women with PCOS and without PCOS (Controls). Studies on children, adolescents (<18 years), pregnant or menopausal-aged women (>50 years) were excluded. Data were pooled by random-effects models and expressed as (standardized) mean differences (MD) and 95% CIs. The risk of bias was assessed by the Newcastle-Ottawa scale (NOS).

OUTCOMES

Fifty-four studies (N = 39 471 participants; [n = 8736 PCOS; 30 735 Controls]) were eligible (96%; [52/54] NOS scores ≥ 7). Women with PCOS had higher cholesterol (MD: 12.78, 95% CI: 1.48 to 24.08 mg/day; P = 0.03; I2 = 19%), lower magnesium (MD: -21.46, 95% CI: -41.03 to -1.91 mg/day; P = 0.03; I2 = 76%), and a tendency for lower zinc (MD: -1.08, 95% CI: -2.19 to -0.03 mg/day; P = 0.05; I2 = 96%) intake, despite lower alcohol consumption (MD: -0.95, 95% CI: -1.67 to 0.22 g/day; P = 0.02; I2 = 0%) versus Controls. Also, women with PCOS had lower total PA (standardized mean difference: -0.38, 95% CI: -0.72 to 0.03; P = 0.03; I2 = 98%). Conversely, energy, macronutrients (carbohydrate, fat, protein, fiber), micronutrients (folic acid, iron, calcium, sodium), glycemic index and glycemic load were similar (all: P ≥ 0.06). Most eligible studies reported lower total adherence to healthy eating patterns or poorer consumption of major food groups (grains, fruits, vegetables, proteins, seeds, nuts, dairy) in women with PCOS, as described narratively since variable study methodology did not permit meta-analyses.

WIDER IMPLICATIONS

Collective evidence supports that women with PCOS have a lower overall diet quality, poorer dietary intakes (higher cholesterol, lower magnesium and zinc) and lower total PA, despite lower alcohol consumption versus those without PCOS. Considerable heterogeneity among studies reinforces the need for research to address any relative contributions of other factors (e.g. genetic, metabolic or sociodemographic) to the observed differences. These clarifications may contribute to future evidence-based guideline recommendations on monitoring and managing PCOS in the era of precision lifestyle medicine.

Anti-Inflammatory Diets in Fertility: An Evidence Review

Infertility is a global health concern affecting 48 million couples and 186 million individuals worldwide. Infertility creates a significant economic and social burden for couples who wish to conceive and has been associated with suboptimal lifestyle factors, including poor diet and physical inactivity. Modifying preconception nutrition to better adhere with Food-Based Dietary Guidelines (FBDGs) is a non-invasive and potentially effective means for improving fertility outcomes. While several dietary patterns have been associated with fertility outcomes, the mechanistic links between diet and infertility remain unclear. A key mechanism outlined in the literature relates to the adverse effects of inflammation on fertility, potentially contributing to irregular menstrual cyclicity, implantation failure, and other negative reproductive sequelae. Therefore, dietary interventions which act to reduce inflammation may improve fertility outcomes. This review consistently shows that adherence to anti-inflammatory diets such as the Mediterranean diet (specifically, increased intake of monounsaturated and n-3 polyunsaturated fatty acids, flavonoids, and reduced intake of red and processed meat) improves fertility, assisted reproductive technology (ART) success, and sperm quality in men. Therefore, integration of anti-inflammatory dietary patterns as low-risk adjunctive fertility treatments may improve fertility partially or fully and reduce the need for prolonged or intensive pharmacological or surgical interventions.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects 5-18% of women, and is a reproductive, metabolic, and psychological condition with impacts across the lifespan. The cause is complex, and includes genetic and epigenetic susceptibility, hypothalamic and ovarian dysfunction, excess androgen exposure, insulin resistance, and adiposity-related mechanisms. Diagnosis is recommended based on the 2003 Rotterdam criteria and confirmed with two of three criteria: hyperandrogenism (clinical or biochemical), irregular cycles, and polycystic ovary morphology. In adolescents, both the criteria of hyperandrogenism and irregular cycles are needed, and ovarian morphology is not included due to poor specificity. The diagnostic criteria generates four phenotypes, and clinical features are heterogeneous, with manifestations typically arising in childhood and then evolving across adolescent and adult life. Treatment involves a combination of lifestyle alterations and medical management. Lifestyle optimisation includes a healthy balanced diet and regular exercise to prevent excess weight gain, limit PCOS complications and target weight reduction when needed. Medical management options include metformin to improve insulin resistance and metabolic features, combined oral contraceptive pill for menstrual cycle regulation and hyperandrogenism, and if needed, anti-androgens for refractory hyperandrogenism. In this Review, we provide an update on the pathophysiology, diagnosis, and clinical features of PCOS, and discuss the needs and priorities of those with PCOS, including lifestyle, and medical and infertility treatment. Further we discuss the status of international evidence-based guidelines (EBG) and translation, to support patient self management, healthcare provision, and to set research priorities.

Association between pregnancy intention and psychological distress among women exposed to different levels of restrictions during the COVID-19 pandemic in Australia

Background

The COVID-19 pandemic has had a negative impact on the mental health of people globally. Significant concerns about health and access to services among women of reproductive age considering pregnancy may cause psychological distress, and in turn increase health risks during and after pregnancy for mothers and offspring.

Objectives

To examine the association between pregnancy intention and psychological distress during the COVID-19 pandemic in Australia, and explore if this association differed based on local viral transmission rates and corresponding levels of pandemic restrictions.

Methods

A nationwide online survey was completed by 849 non-pregnant women aged 18–50 years between 15 October and 7 November 2020. Women were asked about their intention to become pregnant, and psychological distress was assessed using the Kessler Psychological Distress Scale (K10). Multivariable regression analysis examined associations between pregnancy intention and psychological distress. An interaction term was added to the model to examine differences in associations by level of viral transmission rates and lockdown restrictions which was determined based on postcode.

Results

Pregnancy intention was not associated with experiencing (very) high psychological distress in the overall study population (odds ratio (OR) 1.42, 95% CI 0.94, 2.11). The interaction term (p = 0.09) suggested potential differences by level of restrictions and viral transmission rates. In stratified analysis among women living in a location with strict lockdown restrictions and high viral transmission rates leading up to and during the study, those planning to become pregnant were more likely to experience (very) high psychological distress (OR 3.39, 2.04, 5.65) compared with women not planning to become pregnant. Pregnancy intention was not associated with psychological distress among women exposed to lower levels of pandemic restrictions and viral transmission rates (OR 1.17, 0.74, 1.85).

Conclusions

Our findings highlight the need to identify and support women planning pregnancy during a public health crisis to mitigate potential short- and long-term intergenerational negative health outcomes associated with psychological distress.

Coparenting-focused preventive intervention reduces postnatal maternal BMI and buffers impact of cortisol

OBJECTIVE

The postpartum period is a key life stage, contributing to increased maternal obesity risk. Current lifestyle interventions do not consider the role of a woman's partner in reducing stress and supporting lifestyle change. The objective of this study was to assess the effect of an intervention that seeks to enhance coparenting relationship quality on maternal BMI from before conception to 12 months post partum and whether the intervention moderated the association of changes in cortisol and BMI.

METHODS

A randomized controlled trial was used to assess an intervention (eight classes: four during and four following pregnancy) focusing on enhancing couple coparenting relationships during pregnancy and post partum (n = 57) compared with standard care (n = 53).

RESULTS

The main outcome measures were changes in maternal BMI and cortisol. There was a smaller increase in BMI for mothers in intervention compared with control groups (mean [SE], -1.03 [0.42] kg/m² , p = 0.015). There was an interaction between intervention status and cortisol change predicting BMI change (p = 0.026), such that cortisol change significantly predicted BMI change among mothers in the control (p = 0.049) but not the intervention groups (p = 0.204).

CONCLUSIONS

A coparenting intervention improved maternal postpartum BMI, with this effect potentially related to ameliorating the negative effect of stress, as measured by cortisol, on BMI. The role of enhanced coparenting in improving maternal anthropometry warrants urgent attention.

Clinical management of pregnancy in women with polycystic ovary syndrome: An expert opinion

Polycystic ovary syndrome (PCOS) is associated with a higher risk for pregnancy and birth complications according to the specific features associated with PCOS. The features include obesity before and during pregnancy, hyperandrogenism, insulin resistance, infertility, cardiometabolic risk factors, and poor mental health. PCOS is not often recognized as a risk factor for poor pregnancy and birth outcomes in pregnancy care guidelines, while its associated features are. Pregnancy-related risk profile should ideally be assessed for modifiable risk factors (e.g., lifestyle and weight management) at preconception in women with PCOS. Hyperglycaemia should be screened using a 75-g oral glucose tolerance test at preconception or within the first 20 weeks of pregnancy if it has not been performed at preconception and should be repeated at 24-28 weeks of pregnancy. In the absence of evidence of benefit for strategies specific to women with PCOS, the international evidence-based guidelines for the assessment and management of PCOS recommend screening, optimizing, and monitoring risk profile in women with PCOS (at preconception, during and postpregnancy) consistent with the recommendations for the general population. Recommended factors include blood glucose, weight, blood pressure, smoking, alcohol, diet, exercise, sleep and mental health, emotional, and sexual health among women with PCOS. The guidelines recommend Metformin in addition to lifestyle for assisting with weight management and improving cardiometabolic risk factors, particularly in those with overweight or obesity. Letrozole is considered the first-line pharmacological treatment for anovulatory infertility in PCOS. Individualized approach should be considered in the management of pregnancy in PCOS.

Barriers and facilitators to the implementation of lifestyle management in polycystic ovary syndrome: Endocrinologists' and obstetricians and gynaecologists' perspectives

OBJECTIVE

To study the barriers and facilitators to lifestyle management in PCOS from the perspectives of endocrinologists and obstetricians and gynecologists (Ob/Gyns) to inform the translation and implementation of the international evidence-based guideline on lifestyle management in PCOS.

METHODS

11 endocrinologists and ten Ob/Gyns participated in semi-structured interviews and transcripts were thematically analyzed on NVIVO software.

RESULTS

Both endocrinologists and Ob/Gyns supported lifestyle as key to PCOS management but faced systemic barriers of lack of access to allied health services and had limited capacity for in-depth lifestyle discussions. They suggested team-based approach to address these barriers. Endocrinologists reported lifestyle could be a less effective treatment option and most of their patients had challenges with past failed lifestyle attempts while Ob/Gyns perceived the desire to conceive among patients a facilitator. The importance of credible, individualised and PCOS-specific lifestyle advice was highlighted.

CONCLUSION

Endocrinologists and Ob/Gyns perceived lifestyle management as integral to PCOS management but experience barriers to lifestyle management related to specialist care.

PRACTICE IMPLICATIONS

Resources that provide credible, individualized and PCOS-specific lifestyle advice, team care approach and professional development on motivating patients for lifestyle modification may address these barriers.

Assessing patterns of change in lifestyle behaviours by parity: a longitudinal cohort study

BACKGROUND

The time constraints and reprioritization of personal health associated with having children may lead women to adopt less healthy lifestyles. We assessed the patterns of change in weight and lifestyle behaviours associated with having children and whether these differ between primiparous and multiparous women.

METHODS

Data were from Surveys 3 and 5 of the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health. In women who were nulliparous at Survey 3, we assessed changes in weight, energy intake, diet (diet quality, macronutrients and micronutrients), physical activity and sitting time by parity status at Survey 5 using one-way analysis of covariance.

RESULTS

Of 4927 eligible women, 2503 gave birth (1090 primiparous and 1413 multiparous) by Survey 5. Women who had given birth 6 years later increased weight (1.0 kg; 95% CI 0.5, 1.5), energy intake (833.9 kJ/day; 95% CI 706.7, 961.1) and diet quality (1.5 units; 95% CI 0.8, 2.1), but decreased physical activity [-405.0 Metabolic Equivalent of Task.min/week; 95% CI -464.2, -345.8] and sitting time (-1.8 h/day; 95% CI -1.9, -1.6) (adjusted mean differences) relative to those who remained nulliparous. In subgroup analysis involving further stratification by parity, the increase in diet quality was only seen in women who became primiparous and the decrease in sitting time was more marked in multiparous women.

CONCLUSION

Childbearing is associated with increased weight and energy intake, decreased physical activity, increased diet quality and decreased sitting time. More research targeting weight, energy intake and physical activity for improvement in women during the childbearing years is warranted.

The role of sleep in PCOS: what we know and what to consider in the future

INTRODUCTION

Sleep disturbance and clinical sleep conditions disrupt endocrine signals, energy expenditure and nutritional intake. Women with polycystic ovary syndrome (PCOS) are at higher risk of sleep disturbances and clinical conditions. It is possible that sleep may contribute to the exacerbation of PCOS. This review aims to explore the relationship between sleep and chronic disease, particularly in women with PCOS.

AREAS COVERED

This review narratively explores what sleep is, how to measure sleep and the possible mechanisms that support the link between sleep in adipose tissue deposition, insulin resistance and the presentation of PCOS.

EXPERT OPINION

Research shows that disturbed sleep and clinical sleep conditions disrupt energy expenditure. This may increase adipose tissue deposition and exacerbate insulin resistance which are known to worsen the presentation of PCOS. Further, sleep disturbance in women with PCOS may ameliorate any positive lifestyle changes made after diagnosis. Cognitive behavioural therapy interventions for sleep are a successful strategy for the management of sleep disturbances in the general population. However, such interventions are yet to be trialled in women with PCOS. Given the proposed implications, interventions to improve sleep could provide additional support for women with PCOS to successfully implement lifestyle strategies and should be further investigated.

Efficacy and Safety of Nutrient Supplements for Glycaemic Control and Insulin Resistance in Type 2 Diabetes: An Umbrella Review and Hierarchical Evidence Synthesis

Background: Nutrient supplements are widely used for type 2 diabetes (T2D), yet evidence-based guidance for clinicians is lacking. Methods: We searched the four electronic databases from November 2015−December 2021. The most recent, most comprehensive, high-ranked systematic reviews, meta-analyses, and/or umbrella reviews of randomised controlled trials in adults with T2D were included. Data were extracted on study characteristics, aggregate outcome measures per group (glycaemic control, measures of insulin sensitivity and secretion), adverse events, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments. Quality was assessed using A Measurement Tool to Assess Systematic Reviews Version 2.0 (AMSTAR 2). Results: Twelve meta-analyses and one umbrella review were included. There was very low certainty evidence that chromium, Vitamin C, and omega-3 polyunsaturated fatty acids (Ω-3 PUFAs) were superior to placebo for the primary outcome of glycated hemoglobin (HbA1c) (Mean Difference/MD −0.54, −0.54 and ES −0.27, respectively). Probiotics were superior to placebo for HbA1c (Weighted Mean Difference/WMD −0.43%). There was very low certainty evidence that Vitamin D was superior to placebo for lowering HbA1c in trials of <6 months (MD −0.17%). Magnesium, zinc, Vitamin C, probiotics, and polyphenols were superior to placebo for FBG. Vitamin D was superior to placebo for insulin resistance. Data on safety was limited. Conclusions: Future research should identify who may benefit from nutrient supplementation, safety, and optimal regimens and formulations.

Association of Antenatal Diet and Physical Activity-Based Interventions With Gestational Weight Gain and Pregnancy Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Excessive gestational weight gain (GWG) is common and associated with adverse pregnancy outcomes. Antenatal lifestyle interventions limit GWG; yet benefits of different intervention types and specific maternal and neonatal outcomes are unclear.

OBJECTIVE

To evaluate the association of different types of diet and physical activity-based antenatal lifestyle interventions with GWG and maternal and neonatal outcomes.

DATA SOURCES

A 2-stage systematic literature search of MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database was conducted from February 1, 2017, to May 31, 2020. Search results from the present study were integrated with those from a previous systematic review from 1990 to February 2017.

STUDY SELECTION

Randomized trials reporting GWG and maternal and neonatal outcomes.

DATA EXTRACTION AND SYNTHESIS

Data were extracted for random-effects meta-analyses to calculate the summary effect estimates and 95% CIs.

MAIN OUTCOMES AND MEASURES

Outcomes were clinically prioritized, with mean GWG as the primary outcome. Secondary outcomes included gestational diabetes, hypertensive disorders of pregnancy, cesarean section, preterm delivery, large or small for gestational age neonates, neonatal intensive care unit admission, or fetal death.

RESULTS

A total of 117 randomized clinical trials of antenatal lifestyle interventions (involving 34 546 women) were included. Overall lifestyle intervention was associated with reduced GWG (-1.15 kg; 95% CI, -1.40 to -0.91), risk of gestational diabetes (odds ratio [OR], 0.79; 95% CI, 0.70-0.89), and total adverse maternal outcomes (OR, 0.89; 95% CI, 0.84-0.94) vs routine care. Compared with routine care, diet was associated with less GWG (-2.63 kg; 95% CI, -3.87 to -1.40) than physical activity (-1.04 kg; 95% CI, -1.33 to -0.74) or mixed interventions (eg, unstructured lifestyle support, written information with weight monitoring, or behavioral support alone) (-0.74 kg; 95% CI, -1.06 to -0.43). Diet was associated with reduced risk of gestational diabetes (OR, 0.61; 95% CI, 0.45-0.82), preterm delivery (OR, 0.43; 95% CI, 0.22-0.84), large for gestational age neonate (OR, 0.19; 95% CI, 0.08-0.47), neonatal intensive care admission (OR, 0.68; 95% CI, 0.48-0.95), and total adverse maternal (OR, 0.75; 95% CI, 0.61-0.92) and neonatal outcomes (OR, 0.44; 95% CI, 0.26-0.72). Physical activity was associated with reduced GWG and reduced risk of gestational diabetes (OR, 0.60; 95% CI, 0.47-0.75), hypertensive disorders (OR, 0.66; 95% CI, 0.48-0.90), cesarean section (OR, 0.85; 95% CI, 0.75-0.95), and total adverse maternal outcomes (OR, 0.78; 95% CI, 0.71-0.86). Diet with physical activity was associated with reduced GWG (-1.35 kg; 95% CI, -1.95 to -0.75) and reduced risk of gestational diabetes (OR, 0.72; 95% CI, 0.54-0.96) and total adverse maternal outcomes (OR, 0.81; 95% CI, 0.69-0.95). Mixed interventions were associated with reduced GWG only.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found level 1 evidence that antenatal structured diet and physical activity-based lifestyle interventions were associated with reduced GWG and lower risk of adverse maternal and neonatal outcomes. The findings support the implementation of such interventions in routine antenatal care and policy around the world.

Evaluating Evidence-Based Content, Features of Exercise Instruction, and Expert Involvement in Physical Activity Apps for Pregnant Women: Systematic Search and Content Analysis

Background

Guidelines for physical activity and exercise during pregnancy recommend that all women without contraindications engage in regular physical activity to improve both their own health and the health of their baby. Many women are uncertain how to safely engage in physical activity and exercise during this life stage and are increasingly using mobile apps to access health-related information. However, the extent to which apps that provide physical activity and exercise advice align with current evidence-based pregnancy recommendations is unclear.

Objective

This study aims to conduct a systematic search and content analysis of apps that promote physical activity and exercise in pregnancy to examine the alignment of the content with current evidence-based recommendations; delivery, format, and features of physical activity and exercise instruction; and credentials of the app developers.

Methods

Systematic searches were conducted in the Australian App Store and Google Play Store in October 2020. Apps were identified using combinations of search terms relevant to pregnancy and exercise or physical activity and screened for inclusion (with a primary focus on physical activity and exercise during pregnancy, free to download or did not require immediate paid subscription, and an average user rating of ≥4 out of 5). Apps were then independently reviewed using an author-designed extraction tool.

Results

Overall, 27 apps were included in this review (Google Play Store: 16/27, 59%, and App Store: 11/27, 41%). Two-thirds of the apps provided some information relating to the frequency, intensity, time, and type principles of exercise; only 11% (3/27) provided this information in line with current evidence-based guidelines. Approximately one-third of the apps provided information about contraindications to exercise during pregnancy and referenced the supporting evidence. None of the apps actively engaged in screening for potential contraindications. Only 15% (4/27) of the apps collected information about the user’s current exercise behaviors, 11% (3/27) allowed users to personalize features relating to their exercise preferences, and a little more than one-third provided information about developer credentials.

Conclusions

Few exercise apps designed for pregnancy aligned with current evidence-based physical activity guidelines. None of the apps screened users for contraindications to physical activity and exercise during pregnancy, and most lacked appropriate personalization features to account for an individual’s characteristics. Few involved qualified experts during the development of the app. There is a need to improve the quality of apps that promote exercise in pregnancy to ensure that women are appropriately supported to engage in exercise and the potential risk of injury, complications, and adverse pregnancy outcomes for both mother and child is minimized. This could be done by providing expert guidance that aligns with current recommendations, introducing screening measures and features that enable personalization and tailoring to individual users, or by developing a recognized system for regulating apps.

Behaviour Change Techniques in Weight Gain Prevention Interventions in Adults of Reproductive Age: Meta-Analysis and Meta-Regression

Weight gain prevention interventions are likely to be more effective with the inclusion of behaviour change techniques. However, evidence on which behaviour change techniques (BCT) are most effective for preventing weight gain and improving lifestyle (diet and physical activity) is limited, especially in reproductive-aged adults. This meta-analysis and meta-regression aimed to identify BCT associated with changes in weight, energy intake and physical activity in reproductive-aged adults. BCT were identified using the BCT Taxonomy (v1) from each intervention. Meta-regression analyses were used to identify BCT associated with change in weight, energy intake and physical activity. Thirty-four articles were included with twenty-nine articles for the meta-analysis. Forty-three of the ninety-three possible BCT listed in the taxonomy were identified in the included studies. Feedback on behaviour and Graded tasks were significantly associated with less weight gain, and Review behaviour goals was significantly associated with lower energy intake. No individual BCT were significantly associated with physical activity. Our analysis provides further evidence for which BCT are most effective in weight gain prevention interventions. The findings support that the use of key BCT within interventions can contribute to successful weight gain prevention in adults of reproductive age.

Relationships between self-management strategies and physical activity and diet quality in women with polycystic ovary syndrome

OBJECTIVE

To determine the relationships of self-management strategies and physical activity (PA) and diet quality in women with PCOS.

METHODS

An online cross-sectional study involving women (n = 501), 18-45 years in the general Australian community with a self-reported PCOS diagnosis. The self-management and lifestyle behaviour questionnaires were completed between August 2017 and March 2018.

RESULTS

Implementation of PA related self-management strategies increased the odds of meeting PA recommendations [Odds ratio (OR): 2.929 (95%CI: 2.172, 3.951), p < 0.001] but had no association with body mass index (BMI) [OR: 0.-0.984 (95%CI: -1.010, 0.959), p = 0.217] nor perception of self weight [OR: 1.382 (95% CI: 0.700, 2.725), p = 0.352]. Nutrition related self-management strategies were inversely associated with BMI [OR: - 0.115 (95%CI: -7.159, -0.980), p = 0.010] but had no association with diet quality [OR: 0.183 (95%CI: -2.328, 2.800), p = 0.855], energy intake [OR: - 0.092 (95%CI: -1204.443, 527.496) p = 0.438] or weight [OR: - 0.034 (95%CI: -4.020, 1.930), p = 0.491].

CONCLUSIONS

PA self-management strategies were associated with meeting PA recommendations. Nutrition strategies were associated with lower BMI but not diet quality, energy intake or weight in women with PCOS.

PRACTICE IMPLICATIONS

Other behaviour change determinants (e.g. education, skills and self-efficacy) should be considered when designing a PCOS lifestyle programme in conjunction with self-management strategies.

Ethnic differences in response to lifestyle intervention for the prevention of type 2 diabetes in adults: A systematic review and meta-analysis

The risk of type 2 diabetes mellitus (T2DM) varies by ethnicity, but ethnic differences in response to diabetes prevention interventions remain unclear. This systematic review and meta-analysis assessed ethnic differences in the effects of lifestyle interventions on T2DM incidence, glycemic outcomes (fasting glucose, 2-h glucose, HbA_1c ), anthropometric measures (weight, BMI, waist circumference), and lifestyle behaviors (physical activity, energy intake, energy from fat, fiber intake). MEDLINE, EMBASE, and other databases were searched (to June 15, 2020) for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American, and African groups. Forty-four studies were included in meta-analyses. Overall, lifestyle interventions resulted in significant improvement in T2DM incidence, glycemic outcomes, anthropometric measures, physical activity, and energy intake (all P < 0.01). Significant subgroup differences by ethnicity were found for 2-h glucose, weight, BMI, and waist circumference (all P < 0.05) but not for T2DM incidence, fasting glucose, HbA_1c , and physical activity (all P > 0.05). Few studies in non-European groups reported dietary intake. Lifestyle interventions in different ethnic groups may have similar effects in reducing incidence of T2DM although this needs to be confirmed in further studies.

Peer-supported lifestyle interventions on body weight, energy intake, and physical activity in adults: A systematic review and meta-analysis

There is an increasing interest in peer interventions in the management of chronic conditions, but evidence on peer interventions for body weight is lacking. The aim of this study was to examine the efficacy of peer interventions on body weight, energy intake, and physical activity in adults. Interventions delivered by peer (lay member that participants identify with) were included. We searched 14 databases. Outcomes were combined in the meta-analysis using the inverse variance random-effects model. From 2435 articles, 65 articles were included in the systematic review and meta-analysis (n = 15,673). Peer interventions resulted in significant reduction in weight (mean difference [MD] -1.05 kg; 95% confidence interval [CI] -1.68, -0.43; 95% prediction interval [PI] -3.25, 1.14; 28 studies; 7142 participants), BMI (MD -0.24 kg/m² ; 95% CI -0.44, -0.04; 95% PI -0.92, 0.45; 25 studies; 6672 participants), waist circumference (MD -0.75 cm; 95% CI -1.29, -0.21; 95% PI -1.36, -0.14; 12 studies; 4280 participants), and significant increase in physical activity (SMD 0.20; 95% CI 0.09, 0.32; 95% PI -0.46, 0.86; 41 studies; 10,778 participants) with no significant effect on energy intake. This study suggests peer interventions are effective in reducing waist circumference, but further research is needed to confirm its effect on other obesity-related outcomes.

Food Insecurity Prevalence, Severity and Determinants in Australian Households during the COVID-19 Pandemic from the Perspective of Women

This study aimed to describe the prevalence, severity and socio-demographic predictors of food insecurity in Australian households during the COVID-19 pandemic in 2020, from the perspective of women. A cross-sectional online survey of Australian (18–50 years) women was conducted. The survey collected demographic information and utilised the 18-item US Department of Agriculture Household Food Security Survey Module and the Kessler Psychological Distress Scale (K10). A multivariable regression was used to identify predictors of food security status. In this cohort (n = 1005), 19.6% were living in households experiencing food insecurity; with 11.8% experiencing low food-security and 7.8% very low food-security. A further 13.7% of households reported marginal food-security. Poor mental health status (K10 score ≥ 20) predicted household food insecurity at all levels. The presence of more than three children in the household was associated with low food-security (OR 6.24, 95% CI: 2.59–15.03). Those who were renting were 2.10 (95% CI: 1.09–4.05) times likely to experience very low food-security than those owning their own home. The COVID-19 pandemic may have contributed to an increased prevalence of household food insecurity. This study supports the need for a range of responses that address mental health, financial, employment and housing support to food security in Australia.

Nutritional Supplements and Complementary Therapies in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) affects 1 in 5 women of reproductive age, and is characterized by menstrual irregularities, clinical or biochemical hyperandrogenism, and the presence of polycystic ovary morphology. One of the recommended treatment strategies in the international evidence-based guidelines is lifestyle modification, which includes diet and exercise, with the aim of improving a range of health outcomes. The incurable nature of PCOS reinforces the importance of developing novel and innovative symptomatic relief strategies, which are currently the only available approaches for improving quality of life for these women. Women with PCOS tend to be nutrient deficient in many common vitamins and minerals, thought to be associated with the psychological (depression, anxiety, etc.) and physiological (insulin resistance, diabetes, infertility, etc.) sequelae of the condition. Nutrient supplementation and the integration of complementary medicine as adjuncts to traditional lifestyle-based therapies in PCOS could therefore provide additional benefits to these women. In this review, we synthesize the evidence regarding nutrient supplementation and complementary therapies in PCOS, predominantly from randomized controlled trials, systematic reviews, and meta-analyses, to provide an overview of the state of knowledge in this field. The evidence to date suggests that specific vitamins (B-12, inositols, folate, vitamins D, E, and K), vitamin-like nutrients (bioflavonoids and α-lipoic acid), minerals (calcium, zinc, selenium, and chromium picolinate), and other formulations (melatonin, ω-3 fatty acids, probiotics, and cinnamon), as well as some complementary approaches such as acupuncture and yoga may be beneficial in PCOS. However, there remain areas of uncertainty and key limitations in the literature that must be overcome before these therapies can be integrated into routine clinical practice.

Perspectives of Allied Health Professionals on Implementation of the Lifestyle Polycystic Ovary Syndrome Guidelines: A Qualitative Study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition affecting up to 13% of reproductive-aged women. Weight and lifestyle management are key initial treatment strategies for individuals with PCOS, as recommended in international evidence-based guidelines. Allied health professionals, including dietitians, exercise physiologists, and psychologists, are crucial in delivering support for lifestyle and weight management.

OBJECTIVE

Our aim was to explore the barriers and enablers to lifestyle and weight management for individuals with PCOS from the perspectives of allied health professionals.

DESIGN

This was a qualitative study using a phenomenology approach to understand the allied health professionals lived experiences managing the lifestyles of individuals with PCOS. Semi-structured interviews were conducted with allied health professionals (ie, dietitians, exercise physiologists, and psychologist). Interviews were audio-recorded and professionally transcribed. Transcripts were coded inductively and analyzed thematically.

PARTICIPANTS/SETTING

Participants were 15 allied health professionals (ie, 9 dietitians, 5 exercise physiologists, and 1 psychologist) involved in the management of PCOS in Australia (n = 10 in Victoria, n = 5 in other states) and interviewed between June and September 2019.

MAIN OUTCOME MEASURES

Barriers and enablers of allied health professionals relating to the provision of lifestyle and weight management in individuals with PCOS were analyzed.

RESULTS

Barriers relating to individuals with PCOS included insufficient knowledge on lifestyle management; lack of time; socioeconomic disadvantage preventing access to lifestyle support; and psychological issues, such as eating disorders or depression. Barriers relating to health professionals included insufficient knowledge about PCOS and insufficient time during consultation. Barriers relating to the health system included lifestyle recommendations in the PCOS guidelines that are too general and weight-focused, funding system that does not facilitate long-term care, and low integration of care among health professionals.

CONCLUSIONS

Barriers for the individual, health professional, and health system all need to be addressed to improve the implementation of lifestyle management in PCOS care to optimize consistency with the PCOS international evidence-based guidelines.

The Effect of Lifestyle Intervention on Diabetes Prevention by Ethnicity: A Systematic Review of Intervention Characteristics Using the TIDieR Framework

Lifestyle intervention is effective in preventing type 2 diabetes mellitus (T2DM), but the efficacy of intervention components across different ethnic groups is less clear. This systematic review examined the effects of intervention characteristics of lifestyle interventions on diabetes incidence and weight loss by ethnicity using the Template for Intervention Description and Replication (TIDieR) framework. MEDLINE, EMBASE and other databases were searched for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American and African groups. Forty-five studies (18,789 participants) were included in the systematic review and 41 studies in meta-analysis. Meta-analysis showed a high number of intervention sessions was significantly associated with a greater reduction in diabetes incidence (P = 0.043) and weight (P = 0.015), while other intervention characteristics including intervention provider and delivery format did not alter the outcomes (all P > 0.05). Additionally, narrative synthesis showed long-term interventions (≥12 months) were associated with significant diabetes risk reduction for all ethnic groups, while short-term interventions (<12 months) were more effective in weight loss in most ethnic groups. There may be ethnic preferences for the optimal number of intervention sessions.

Weight gain and lifestyle factors in women with and without polycystic ovary syndrome

STUDY QUESTION

Do extrinsic factors including lifestyle, psychosocial factors and healthcare professional engagement independently contribute to weight gain in women with and without polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Women with PCOS had a higher rate of weight gain than women without PCOS which was most marked in those with unhealthy lifestyles.

WHAT IS KNOWN ALREADY

Women with PCOS have a higher prevalence of overweight/obesity and greater weight gain than women without PCOS. The association of lifestyle factors with weight change in PCOS is not known.

STUDY DESIGN, SIZE, DURATION

The study was a population-based observational study with data collected from seven surveys over 19 years (N = 14 127; Survey 1) involving women with and without PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used data from the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with PCOS gained more weight annually (0.26 kg/year; 95% CI 0.12, 0.39; P < 0.0001) and over 19 years (4.62 kg; 95% CI 3.04, 6.21; P < 0.0001) than women without PCOS (adjusted analyses). For all women, there were positive associations between weight gain and energy intake, sitting time and stress; inverse associations with fibre intake and physical activity (PA); and no associations with diet quality, glycaemic index, healthcare utilization, depression or anxiety. There were interactions between lifestyle factors (energy intake P = 0.006, glycaemic index P = 0.025, sitting time P = 0.041 and PA P = 0.021), PCOS status and time such that weight gain varied between women with and without PCOS according to these factors.

LIMITATIONS, REASONS FOR CAUTION

The limitations of this study include the use of self-reported measures such as diet, PA, sitting time, psychological factors and health care utilization.

WIDER IMPLICATIONS OF THE FINDINGS

While women with PCOS are more prone to weight gain, lifestyle factors have a more profound impact on weight gain in women with PCOS than without PCOS. These study findings have implications for understanding the mechanisms of weight gain in women with PCOS. They also highlight the importance of early lifestyle intervention as soon as PCOS is diagnosed to address modifiable extrinsic factors and prevent excess weight gain and worsening of the clinical features of PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

M.A.A. is funded by the Monash International Tuition Scholarship and Monash Graduate Scholarship and L.J.M. is funded by a National Heart Foundation Future Leader Fellowship. The authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Preventing weight gain in adults: A systematic review and meta-analysis of randomized controlled trials

Weight gain prevention is a global public health priority to address escalating adiposity in adults. This review evaluates the efficacy of weight gain prevention trials targeting adults aged 18-50 years and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Trials of any duration from inception to May 2020 that evaluated a weight gain prevention intervention (using either prescriptive diet, prescriptive physical activity, prescriptive diet, and/or physical activity or non-prescriptive lifestyle) and included weight or body mass index (weight [kg]/height [m² ]) were eligible. Twenty-nine trials across 34 publications (participants n = 37,407) were included. Intervention resulted in less weight gain compared with controls (-1.15 kg [95% CI -1.50, -0.80 kg] p < 0.001). Subgroup analysis demonstrated greater effectiveness with prescriptive (-1.60 kg [95% CI -2.00, -1.19] p < 0.001) compared with non-prescriptive (-0.81 kg [95% CI 1.10, -0.53] p < 0.001) intervention types. Interventions had greatest impact in healthy weight (18.5-24.9 kg/m² ) (-0.82 kg [95% CI -1.5, -0.50] p < 0.001) or overweight (25.0-29.9 kg/m² ) (-1.48 kg [95% CI -1.85, -1.12] p < 0.001) compared with obese populations (≥30.0 kg/m² ) (-0.56 kg [95% CI -1.40, 0.27] p = 0.19). These findings demonstrate that lifestyle intervention prevents cumulative weight gain in non-obese adults, with future research required to inform cost-effectiveness and implementation feasibility.

A Pilot Study on the Impact of Menstrual Cycle Phase on Elite Australian Football Athletes

The effect of the menstrual cycle on athlete performance, wellbeing and perceived exertion and fatigue is not well understood. Furthermore, it has not been investigated specifically in Australian Football athletes. This pilot study aimed to explore how naturally menstruating Australian Football athletes may be affected by menstrual cycle phase. The data collected from the routine monitoring of five naturally menstruating athletes (average menstrual cycle length of 28 ± 3 [SD] days) in one team (athlete age range 18–35 years) competing in the Women’s Australian Football League during the 2019 season were retrospectively analysed to compare performance (countermovement jump parameters and adductor squeeze pressure), perceived exertion, perceived fatigue and wellbeing (perceived sleep quality, stress and soreness) outcomes between the follicular and luteal phases. Performance, perceived exertion, stress and soreness did not appear to be affected by menstrual cycle phase (p > 0.17). However, perceived fatigue appeared to be significantly greater (p = 0.042) and sleep quality worse (p = 0.005) in the luteal phase. This pilot study suggests further research focusing on the effect of menstrual cycle phase on subjective fatigue and wellbeing is warranted.

1209Physical activity and sitting time across postpartum life stages: A cross-sectional analysis

Background

Physical activity (PA) is beneficial for psychological wellbeing and weight management but is generally low in postpartum women. This study aimed to investigate how PA and sitting time (ST) varied with time since last childbirth.

Methods

Data from survey 5 (N = 5219) of the 1973-8 birth cohort (31 – 36 years) of the Australian Longitudinal Study on Women’s Health were used to assess association of time since last childbirth (0–6, 7–12 and &gt;12 months) with PA and ST using multiple linear regression.

Results

In adjusted model, PA was lower at 0–6 (-238.5METmin/day; 95%CI -319.6, -157.4) and 7–12 (-81.2METmin/day; 95%CI -157.0, -5.5) than &gt;12 months postpartum. ST was longer at 0–6 (0.65hours/day; 95%CI 0.39, 0.91), but not different at 7–12 than at &gt; 12 months postpartum. Overall, higher BMI and being pregnant were inversely associated, while being single, higher stress levels and better self-rated health were positively associated with PA. Conversely, better self-rated health, having more children and breastfeeding were inversely associated, while higher BMI, income and stress levels were positively associated with ST.

Conclusion

In the first 6 months, women are less physically active and sit longer than beyond the first postpartum year. This may be due to the high demands of infant feeding/care in early postpartum suggesting a need for additional support to safely resume PA e.g. walking and reduce sitting time.

Key message

The first 6 months postpartum is characterized by lower PA and longer ST which may contribute to obesity and chronic diseases.

Informing a PCOS Lifestyle Program: Mapping Behavior Change Techniques to Barriers and Enablers to Behavior Change Using the Theoretical Domains Framework

This article aimed to identify the behavior change techniques (BCTs) based on facilitators and barriers to lifestyle management in women with polycystic ovary syndrome (PCOS) according to the behavior change wheel (BCW). This qualitative study design using inductive thematic analysis following semistructured interviews (n = 20) identified barriers and enablers to lifestyle management. These were then mapped to Capability, Opportunity, Motivation-Behavioral Model (COM-B) constructs and the corresponding Theoretical Domains Framework (TDF) domains. This study included women with PCOS residing in Australia. Main outcome measures include intervention functions, policy categories, and BCTs described in the BCW. Twenty-three BCTs were recognized to influence behavior change in women with PCOS. Factors were categorized into the subcomponents of the COM-B: psychological capability (e.g., lack of credible information), physical capability (e.g., managing multiple health conditions), physical opportunity (e.g., limited access to resources), social opportunity (e.g., adequate social support), reflective motivation (e.g., positive health expectancies following behavior change), and automatic motivation (e.g., emotional eating). Future research should use this work to guide PCOS lifestyle intervention development and then test intervention effectiveness through an experimental phase to provide empirical evidence for wider use and implementation of tailored, theory-informed PCOS lifestyle programs as part of evidence-based PCOS management.

The role of midwives and obstetrical nurses in the promotion of healthy lifestyle during pregnancy

Women with maternal obesity, an unhealthy lifestyle before and during pregnancy and excess gestational weight gain have an increased risk of adverse pregnancy and birth outcomes that can also increase the risk of long-term poor health for them and their children. Pregnant women have frequent medical appointments and are highly receptive to health advice. Healthcare professionals who interact with women during pregnancy are in a privileged position to support women to make lasting healthy lifestyle changes that can improve gestational weight gain and pregnancy outcomes and halt the intergenerational nature of obesity. Midwives and obstetrical nurses are key healthcare professionals responsible for providing antenatal care in most countries. Therefore, it is crucial for them to build and enhance their ability to promote healthy lifestyles in pregnant women. Undergraduate midwifery curricula usually lack sufficient lifestyle content to provide emerging midwives and obstetrical nurses with the knowledge, skills, and confidence to effectively assess and support healthy lifestyle behaviours in pregnant women. Consequently, registered midwives and obstetrical nurses may not recognise their role in healthy lifestyle promotion specific to healthy eating and physical activity in practice. In addition, practising midwives and obstetrical nurses do not consistently have access to healthy lifestyle promotion training in the workplace. Therefore, many midwives and obstetrical nurses may not have the confidence and/or skills to support pregnant women to improve their lifestyles. This narrative review summarises the role of midwives and obstetrical nurses in the promotion of healthy lifestyles relating to healthy eating and physical activity and optimising weight in pregnancy, the barriers that they face to deliver optimal care and an overview of what we know works when supporting midwives and obstetrical nurses in their role to support women in achieving a healthy lifestyle.

Implementation of evidence-based PCOS lifestyle management guidelines: Perceived barriers and facilitators by consumers using the Theoretical Domains Framework and COM-B Model

BACKGROUND

The 2018 Evidence-Based Polycystic Ovary Syndrome (PCOS) Clinical Guidelines recommend lifestyle management as first-line treatment for PCOS, yet implementation of PCOS lifestyle programs into practice is not well understood.

OBJECTIVE

To complete systematic intervention mapping by identifying the facilitators and barriers to lifestyle management in women with PCOS using the theoretical domains framework (TDF) and the Capacity, Opportunity, Motivation and Behaviour model (COM-B).

PATIENT INVOLVEMENT

Women (N = 20) in Australian with PCOS were interviewed.

METHODS

Telephone semi-structured interviews.

RESULTS

Nine themes mapped onto seven TDF domains and the COM-B. Capability: psychological co-morbidities, knowledge and awareness of lifestyle change and ability to identify and resolve barriers. Opportunity: presence of other medical conditions, access to practical resources and availability of social support.

MOTIVATION

outcomes expectancies of lifestyle behaviour, personal values, enjoyment and readiness to change and the impact of stress on lifestyle choices.

DISCUSSION

This is the first study to explore barriers and facilitators to lifestyle change from the perspectives of women with PCOS using the TDF and COM-B. Addressing these themes will facilitate patient-centred care and long-term behaviour change.

PRACTICAL IMPLICATIONS

May increase the efficacy and effectiveness of PCOS lifestyle programs and reduce the risk of PCOS-associated disease in this population.

Support Seeking in the Postpartum Period: Content Analysis of Posts in Web-Based Parenting Discussion Groups

Background

The transition from pregnancy to motherhood is a major developmental phase that can be challenging for both women and their families. For new mothers, the postpartum period is recognized as a critical period for increased risk of both physical and mental health concerns. For this reason, it is imperative that women receive accurate, evidence-based information during this time.

Objective

This study aims to explore the conversations of new mothers on a web-based parenting forum to investigate what topics or concerns are being discussed.

Methods

A leading Australian web-based support forum for women before and after birth was used to obtain a sample of posts from the mothers of infants aged 0-12 months. Quantitative data (word frequencies and sentiment analysis) and qualitative data (post content) were extracted from discussion threads and examined to determine sentiments and theoretical storylines.

Results

In total, 260 posts were sampled. Infant care was the most prominent overarching topic discussed, with feeding and sleep being the most discussed subtopics. Discussions about maternal care were much less frequent but included questions about birth recovery, breastfeeding concerns, and interconception. A pattern of behavior emerged within the posts. This pattern resembled a cycle of learning across five phases: help seeking, solution ideation, testing and skill development, consolidation, and empowerment and improved mental well-being. A dynamic interplay was observed as mothers navigated new concerns or developmental changes.

Conclusions

Engagement in web-based forums to seek help and support during the postpartum period was common, with infant health and well-being being the primary concerns for new mothers during this time. The identification of a maternal learning cycle within the forum underscores the contributory role of web-based communities in maternal peer social support, information seeking, and early parenting practices.

Enablers and barriers to women's lifestyle behavior change during the preconception period: A systematic review

Healthy lifestyle behaviors during the preconception period are important to optimize maternal and child outcomes, including weight. However, the majority of women do not have optimal preconception lifestyle behaviors. This systematic review explored enablers and barriers to women's preconception lifestyle behaviors using the Capability, Opportunity, Motivation, Behaviour (COM-B) model and Theoretical Domains Framework (TDF). Preconception was defined as the time before conception, capturing planned and unplanned pregnancies. Medline Complete, EMBASE, PsycINFO, and CINAHL were searched for peer-reviewed, quantitative and qualitative primary studies (English, 2006-2020) that explored enablers and barriers to lifestyle behaviors (diet, physical activity, smoking, alcohol use, supplement intake). Forty-two studies (of 3406) were included, assessing supplement use (n = 37), diet (n = 10), smoking (n = 10), alcohol use (n = 8), and physical activity (n = 5). All three COM-B components were identified only for diet and supplement use. Of the 14 TDF domains, 7 were identified: knowledge, beliefs about capabilities, beliefs about consequences, goals, intentions, social support, and environmental context and resources. The presence/absence of knowledge on healthy behaviors was the most commonly assessed enabler/barrier. Future studies should explore a wider range of factors influencing preconception women's capability, opportunity, and motivation to modify their lifestyle behaviors.

Polycystic Ovary Syndrome Models of Care: A Review and Qualitative Evaluation of a Guideline-Recommended Integrated Care

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and many women are dissatisfied with their healthcare under the current fragmented health services. Here, we review existing literature on PCOS healthcare services and qualitatively evaluate an integrated PCOS service based on experiences of women with PCOS. Limited prior PCOS-dedicated services have been studied and their quantitative and efficacy-focused evaluations are summarized. Here, we also provide a broader PCOS service evaluation via semistructured interviews and surveys, with thematic analysis based on a predetermined evaluation framework. Fifteen women completed interviews and surveys. Overall the integrated, evidence-based PCOS service was well-received and women were generally satisfied with appropriateness, effectiveness, and reported positive health impact resulting from the service. Integrated care, tailored treatments, education, lifestyle support, and laser therapy were highly valued. Patients reported improvements on symptoms, understanding and confidence in managing PCOS, and emotional well-being. Elements of efficiency in the initial stages, awareness and communication, and the need for service expansion and tensions between evidence-based treatments and patient preferences were also captured to guide improvement. Further research into models of care is recommended to meet the needs of women with PCOS.

Sleep disturbances may influence lifestyle behaviours in women with self-reported polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with a higher prevalence of sleep disturbances and obesity. Treatment of PCOS includes modifying lifestyle behaviours associated with weight management. However, poor sleep in the non-PCOS population has been associated with poorer lifestyle behaviours. The aim was to investigate whether sleep disturbance confounds or modifies the association between lifestyle factors and PCOS. This was a cross-sectional analysis from the Australian Longitudinal Study on Women's Health cohort aged 31-36 years in 2009 were analysed (n 6067, 464 PCOS, 5603 non-PCOS). Self-reported data were collected on PCOS, anthropometry, validated modified version of the Active Australia Physical Activity survey, validated FFQ and sleep disturbances through latent class analysis. Women with PCOS had greater adverse sleep symptoms including severe tiredness (P = 0·001), difficulty sleeping (P < 0·001) and restless sleep (P < 0·001), compared with women without PCOS. Women with PCOS also had higher energy consumption (6911 (sd 2453) v. 6654 (sd 2215) kJ, P = 0·017), fibre intake (19·8 (sd 7·8) v. 18·9 (sd 6·9) g, P = 0·012) and diet quality (dietary guidelines index (DGI)) (88·1 (sd 11·6) v. 86·7 (sd 11·1), P = 0·008), lower glycaemic index (50·2 (sd 4·0) v. 50·7 (sd 3·9), P = 0·021) and increased sedentary behaviour (6·3 (sd 2·8) v. 5·9 (sd 2·8) h, P = 0·009). There was a significant interaction between PCOS and sleep disturbances for DGI (P = 0·035), therefore only for women who had adequate sleep was PCOS associated with a higher DGI. For women with poorer sleep, there was no association between PCOS and DGI. The association between PCOS and improved diet quality may only be maintained if women can obtain enough good quality sleep.

The Relationship of Diet and Physical Activity with Weight Gain and Weight Gain Prevention in Women of Reproductive Age

Reproductive-age women often see increased weight gain, which carries an increased risk of long-term overweight and obesity and adverse maternal and child health outcomes. Supporting women to achieve optimal weight through lifestyle modification (diet and physical activity) is of critical importance to reduce weight gain across key reproductive life-stages (preconception, pregnancy and postpartum). This review comprehensively summarizes the current state of knowledge on the contribution of diet and physical activity to weight gain and weight gain prevention in reproductive-aged women. Suboptimal diets including a higher proportion of discretionary choices or energy intake from fats, added sugars, sweets or processed foods are associated with higher weight gain, whereas increased consumption of core foods including fruits, vegetables and whole grains and engaging in regular physical activity are associated with reduced weight gain in reproductive age women. Diet and physical activity contributing to excessive gestational weight gain are well documented. However, there is limited research assessing diet and physical activity components associated with weight gain during the preconception and postpartum period. This review highlights the need for further research to identify key dietary and physical activity components targeting the critical windows of reproductive life-stages in women to best guide interventions to prevent weight gain.

Longitudinal Weight Gain and Lifestyle Factors in Women With and Without Polycystic Ovary Syndrome

Background: While women with polycystic ovary syndrome (PCOS) have a higher prevalence of overweight/obesity and increased weight gain than women without PCOS, the association of lifestyle behaviours with weight change is not known. Methods: We used data from the 1973–78 cohort of the Australian Longitudinal Study on Women’s Health for longitudinal analysis over 19 years (N=14127 at survey 1). Linear mixed-effects models were used to examine weight change and its association with diet, physical activity and sitting time, adjusted for sociodemographic, psychological factors and health care utilisation. Results: Women with PCOS gained more weight annually (0.27 kg/year, 95% CI 0.14, 0.40; P<0.001) and over 19 years (15.3 kg 95% CI 10.9, 19.7 Vs. 10.8 kg 95% CI 5.5, 16.2) than women without PCOS. There was a three-way interaction between energy intake (0.31 kg, 95% CI 0.004, 0.61; P=0.047), glycaemic index (0.44 kg, 95% CI 0.13, 0.74; P=0.005), sitting time (0.55 kg 95% CI 0.002, 1.10; P=0.049), physical activity (-0.37 kg, 95% CI -0.69, -0.05; P=0.022) and PCOS and time. While women with PCOS had higher weight gain than those without PCOS overall, this difference was greater for women with PCOS with higher energy intake, glycaemic index and longer sitting time and those not meeting PA guidelines. Conclusions: Women with PCOS had a higher rate of weight gain than those without PCOS with those with unhealthy lifestyle behaviours having the greatest weight gain. Women with PCOS may be biologically predisposed to weight gain when experiencing adverse lifestyle factors. This reinforces the contribution of lifestyle factors to weight change and the importance of early lifestyle intervention in PCOS.

Reducing Postpartum Weight Retention: A Review of the Implementation Challenges of Postpartum Lifestyle Interventions

Postpartum weight retention (PPWR) is a strong predictor of obesity in later life with long term health consequences in women. Suboptimal lifestyle behaviours (e.g., diet and physical activity) contribute to PPWR. Postpartum lifestyle interventions are known to be efficacious in reducing PPWR; however, there are challenges to their successful implementation. To inform implementation, this narrative review provides an overview of the factors that contribute to PPWR, the efficacy of existing postpartum lifestyle interventions and key determinants of effective implementation using the Consolidated Framework for Implementation Research (CFIR) across intervention characteristics, implementation process, individual characteristics and outer and inner setting. We then suggest strategies to improve the translation of evidence into large-scale interventions that deliver on health impact in postpartum women. We have identified gaps that need to be addressed to advance postpartum lifestyle research, including the involvement of postpartum women and community members as key stakeholders for optimal reach and engagement, more complete reporting of intervention characteristics to optimize translation of evidence into practice, capacity building of health professionals and guidelines for postpartum lifestyle management.