Dietary interventions in

Obese Pregnancy:

An Australian study and systematic review of the literature

Professor Julie Quinlivan

Prevalence

In Australia and New Zealand,

35% of women presenting for antenatal care are overweight or obese

Ball K et al, Pub Hlth Nutr 2003; Lederman SA. Obstet Gynecol 1993; Gunderson & Abrams Epidemiol Rev 2000.

Prevalence

So we have more women than ever PRESENTING for antenatal care who are overweight or obese

This is then compounded by women PUTTING ON more weight in pregnancy than required.

Ball K et al, Pub Hlth Nutr 2003; Lederman SA. Obstet Gynecol 1993; Gunderson & Abrams Epidemiol Rev 2000.

2. Increasing weight gain in pregnancy

The excess weight gain in pregnancy is FAT women must lose afterwards.

NHMRC (Australia) Clinical Practice Guidelines for the management of overweight and obesity in adults, Commonwealth of Australia, Canberra, 2003.; Lederman SA. Obstet Gynecol 1993; 82: 148-55; Hytten and Chamberlerein , Clinical psychology in Obstetrics. Blackwell Scientific Publications: Oxford, 1980; Linne Y. Obesity reviews 2004; Chesley and Weight changes and water balance in normal and toxic pregnancy. Am J Obstet Gynecol 1944; 48: 565-593. Bongain , Euro J Obstet Gynaecol Repro Biol 1998.

Period Mean weight gain in pregnancy

1960-1970 8.5-10kg

1980-1990 9-11kg

1990-2000 10-14kg

2000-2010 13-15kg

NHMRC (Aust) reports that young adult women are at particular risk of weight gain.

Childbirth is a particular risk.

Up to 20% of women gain >5kg by 6 months postpartum.

Ball K et al, Pub Hlth Nutr 2003; Lederman SA. Obstet Gynecol 1993; Gunderson & Abrams Epidemiol Rev 2000.

Ref: 2B blog spot.com

Implications of obesity

Increased pre-pregnancy weight and weight gain during pregnancy ADVERSELY increases:* Gestational diabetes;* Macrosomia;* Preterm;* Postdates;* Operative delivery;* Hypertension;* Infections; * Clotting disorders.

What is the impact of maternal BMI on GDM?

25-30 31-40 40+

Rate of GDM

2-5% 7-12% 17-25%

Example: GDM

The obesity epidemic and an increase in pregnancy weight gain have increased gestational diabetes.....

.....and then, along comes evidence that we have been under diagnosing gestational diabetes to the detriment of women and their babies.

Hyperglycaemia and Adverse Pregnancy

Outcomes study.

It found that there was a CONTINUOUS relationship between blood glucose and adverse neonatal and maternal outcomes.

The trial suggested that new guidelines were required to diagnose GDM.Cur Opinion Obstet Gynecol 2011; 23(2): 72-5.

HAPO

Two large RCT implementing treatment at old diagnostic criteria for GDM versus the new HAPO criteria for GDM

Both RCT found SIGNIFICANT IMPROVEMENTS in MATERNAL and NEONATAL outcomes with the treatment of GDM under the new HAPO guidelines.Cur Opinion Obstet Gynecol 2011; 23(2): 72-5.

The Randomised trials

Birth weight >90th centile

Cord blood C-peptide >90th centile

Caesarean section

Neonatal hypoglycaemia

Pre eclampsia

Preterm birth

Shoulder dystocia

Birth injury

NICU admission

HyperbilirubinaemiaAnnals New York Acad Science 2010; 1205:88-93

Significant improvements

International association of diabetes and pregnancy study groups (IADPSG) recommendation:

All pregnant women should be offered a 75g oral GTT between 24-28 weeks gestation.

An ABNORMAL result is any one of the following:

Fasting 5.1 g/dL (92mg/dL)

1 hr 10.0 g/dL (180mg/dL)

2 hr 8.5 g/dL (153mg/dL)

Post HAPO

New guidelines and workload

All GTT results from SW and N/Sydney analysed by old and HAPO criteria.

They found an INCREASE in workload

29-32%

ANZJOG 2010; 50(5): 439-43.

Options

So we need interventions in pregnancy directed towards obese women that aim to restrict weight gain in pregnancy to IOL recommendations and try to reverse the increase in GDM.

Target weight gains

New Institute of Medicine 2009 guidelines for weight gain in pregnancy

Overweight women BMI 25 to 29.96.8 to 11.3kg

Obese women BMI >304.9 to 9kg

Options

* Exercise X

* Psychological X

* Diet ????

Aim

Does a 4-step multidisciplinary approach to the management of obese pregnant women reduce weight gain and gestational diabetes in obese pregnant women?

Quinlivan JA et al, ANZJOG 2011

.

Triangle of intervention

HIGH

LOW

The 4 steps

1. Continuity of care;

2. Measure Weight gain at each visit;

3. Repeated short interventions by a food technologist;

4. An initial assessment by a clinical psychologist

Hypotheses

The 4-step approach would reduce the incidence of gestational diabetes;

The reduction in gestational diabetes would be mediated through a reduction in maternal weight gain in pregnancy; and

This would occur without an impact upon birth weight.

Controls

Routine antenatal care.

This consisted of midwifery, obstetrician and general practitioner antenatal clinics, with access to high-risk antenatal clinics if indicated on medical grounds.

Intervention

Women in the intervention group attended a study-specific antenatal clinic which differed in routine care only in the following four steps.

All other clinic protocols across control and intervention clinics were identical and followed The Three Centre Consensus Statement on Maternity Care

Variables Intervention Control P-value

GDM (%) 6 29 0.04

Weight gain (kg)

7.0 (0.65) 13.8 (0.67) <0.001

Birthweight 3.5 (0.07) 3.4 (0.10) 0.162

Outcome data

Variables Intervention Control P-value

GDM (%) 6 29 0.04

Weight gain (kg)

7.0 (0.65) 13.8 (0.67) <0.001

Birthweight 3.5 (0.07) 3.4 (0.10) 0.162

Outcome data

IOL : Obese women 4.9 to 9kg

Variables (N) First visit(N=63)

Final visit(N=63)

Fizzy drinks 61 23

Water 2 47

Fast food 40 21

Home cooked meal 23 42

Fresh fruit 5 42

Fresh vegetable 11 42

Diet changes

Quinlivan et al, 2011 Australia

EFFECTIVE

1. Continuity of care

2. Weigh at every antenatal visit

3. Short visit with nutritionist (5 minutes) to review:

• What did the patient eat the day before?

• Immediate written feedback on diet

4. Psychological assessment and intervention if required.

What do other RCT in the literature show?

Is there a pattern?

Can we develop an even simpler intervention that works?

All RCT

There are currently FOUR RCT of dietary interventions in obese pregnant women.

1. Wolff et al. (2008) Denmark

2. Thornton et al. (2009) USA

3. Guelinckx et al.  (2010) Belgium

4. Quinlivan et al, 2011 Australia

Wolff et al. (2008) Denmark

1. Weight at every antenatal visit and discussion of weight gain by the provider

2. One hour visit with a dietician followed by 9 x 30 minute visits. Total of 10 visits.

REPEATED INTERVENTION EFFECTIVE

Thornton et al. (2009) USA

1. Continuity of care

2. Initial visit by dietician.

3. Food diary maintained by patient and discussed at every antenatal visit by providers.

REPEATED INTERVENTION EFFECTIVE

Guelinckx et al.  (2010) Belgium

1. Continuity of care

2. Single visit by a dietician.

SINGLE INTERVENTION

NOT EFFECTIVE

Quinlivan et al, 2011 Australia

REPEATED

INTERVENTION

EFFECTIVE

Meta analysis – Impact upon maternal weight gain

Overall (I-squared = 89.3%, p = 0.000)

ID

Guelinckx et al. (2010)

Quinlivan et al. (2011)

Study

Wolff et al. (2008)

Thornton et al. (2009)

-6.46 (-7.55, -5.37)

WMD (95% CI)

-0.80 (-3.30, 1.70)

-6.80 (-8.63, -4.97)

-6.70 (-10.27, -3.13)

-9.10 (-10.93, -7.27)

267

(SD); Treatment

65, 9.8 (7.6)

63, 7 (5.2)

N, mean

23, 6.6 (5.5)

116, 5 (6.8)

270

(SD); Control

65, 10.6 (6.9)

61, 13.8 (5.2)

N, mean

28, 13.3 (7.5)

116, 14.1 (7.4)

100.00

Weight

19.20

35.68

%

9.36

35.75

-6.46 (-7.55, -5.37)

WMD (95% CI)

-0.80 (-3.30, 1.70)

-6.80 (-8.63, -4.97)

-6.70 (-10.27, -3.13)

-9.10 (-10.93, -7.27)

267

(SD); Treatment

65, 9.8 (7.6)

63, 7 (5.2)

N, mean

23, 6.6 (5.5)

116, 5 (6.8)

Treatment reduces weight gain Treatment increases weight gain

0-10.9 0 10.9

Meta analysis – Impact upon maternal weight gain

Overall (I-squared = 89.3%, p = 0.000)

ID

Guelinckx et al. (2010)

Quinlivan et al. (2011)

Study

Wolff et al. (2008)

Thornton et al. (2009)

-6.46 (-7.55, -5.37)

WMD (95% CI)

-0.80 (-3.30, 1.70)

-6.80 (-8.63, -4.97)

-6.70 (-10.27, -3.13)

-9.10 (-10.93, -7.27)

267

(SD); Treatment

65, 9.8 (7.6)

63, 7 (5.2)

N, mean

23, 6.6 (5.5)

116, 5 (6.8)

270

(SD); Control

65, 10.6 (6.9)

61, 13.8 (5.2)

N, mean

28, 13.3 (7.5)

116, 14.1 (7.4)

100.00

Weight

19.20

35.68

%

9.36

35.75

-6.46 (-7.55, -5.37)

WMD (95% CI)

-0.80 (-3.30, 1.70)

-6.80 (-8.63, -4.97)

-6.70 (-10.27, -3.13)

-9.10 (-10.93, -7.27)

267

(SD); Treatment

65, 9.8 (7.6)

63, 7 (5.2)

N, mean

23, 6.6 (5.5)

116, 5 (6.8)

Treatment reduces weight gain Treatment increases weight gain

0-10.9 0 10.9

The future intervention

1. The intervention needs to be repeated.

2. The intervention can be short.

3. The intervention should include a written element retained by the woman.

4. The intervention can be undertaken by anyone in the care team.

A 3 step model

Step 1: Continuity of care;

Step 2: Weight at every antenatal visit;

Step 3: Repeated review by the ANC

provider of a DIETARY DIARY.

Enrole:Women presenting <20 weeks with a BMI>25

Intervention3 step model versus existing model of care

10 Outcomes: * Reduce gestational weight gain* Reduce gestational diabetes (15% to 10%)

Sample size:N=1450

The Diary RCT

The DIARY trial

Key elements of the diary...1. The 3 Do.2. The 3 Don’t.3. Diary pages where the patient writes in the previous day’s food and drink intake.4. Space for care provider to provide written feedbackat each ANC.

Do and Don’t

3 Do...•Drink water•Eat fresh vegetables•Eat home cooked meals

3 Don’t...•Smoke•Drink alcohol•Drink fizzy drinks, cordial and juices

Thankyou