vinter o&p2013
Post on 18-Dec-2014
95 Views
Preview:
DESCRIPTION
TRANSCRIPT
Christina VinterMD, PhD
Department of Gynaecology and ObstetricsOdense University Hospital
University of Southern Denmark
Lifestyle intervention during pregnancy
Today´s presentation
• Types of lifestyle intervention• RCT• Systematic reviews and metaanalysis• IPD metaanalysis• Weight loss prior to conception• Future perspectives
Fertility
Childhood AdulthoodPostpartum
Fertility Embryo Fetus Pregnancy
InfertilityMiscarriageCongenital anomalies
StillbirthFetal growthMonitoring
GDMPreeclampsiaThromboembolism
InfectionsThromboembolismLow breastfeeding rateWeight retention
Childhood obesity
ObesityMetabolic syndrome
Delivery
Induction of labourInstrumental deliveryCesarean deliveryAnaesthetic compl.Intrapartum monitoring
Sebire et al 2001, Chu et al 2007, Metwally et al 2008, Heslehurst et al 2008, Stothard et al 2009, Ovesen et al 2011, Nøhr et al 2012
Gestational Weight Gain(Institute of Medicine 2009)
Prepregnancy BMI category
Total weight gain
Underweight
(< 18.5 kg/m2)
12.5-18 kg
Normal-weight
(18.5-24.9 kg/m2)
11.5-16 kg
Overweight
(25.0-29.9 kg/m2)
7-11.5 kg
Obese
(≥ 30.0 kg/m2)
5-9 kg
IOM: Weight gain during pregnancy: reexamining the guidelines, 2009
Intervention in pregnancy
+ Pregnancy is a ”window” of opportunities+ Women concerned with the health of their baby+ Frequent contact with health care professionals
-9 months of pregnancy / a life with obesity-Two lifes to consider - Potential harm for the infants
Intervention in pregnancy
Diet Physical activity
Behavioral
Evaluation of intervention
• Gestational Weight Gain (GWG)
• >/< IOM weight gain recommendations
• Maternal outcomes• Neonatal outcomes• Metabolic parameters• Psychological parameters• Long term outcomes
“Globesity”
World Health Organization:
• Worldwide obesity has more than doubled since 1980• In 2008 over 200 million men and 300 million women were obese• 43 million children under the age of five were overweight in 2010• Obesity is preventable
• RCT, BMI>30, n= 50• 10 times individual 1h dietary counseling with
dieticians• Reduction in GWG: 6.6 vs 13.3 kg, p=0.002• No effect on clinical outcomes
Denmark
Wolff S et al, Int J Obes, 2008
• RCT, BMI>29, n= 205• 1) Normal care 2) Brochure 3) Intervention • Intervention: 4 group sessions with a midwife, focus
on energy intake and expenditure, healthy food pyramid
• Significant reduction in GWG: normal care 13.5kg vs brochure 9.5kg vs intervention 10.6kg
• Level of anxiety significantly decreased in intervention group and increased in normal care group
• No effect on obstetric and neonatal outcomes
Belgium
Bogaerts et al, Int J Obesity, 2012
• RCT, BMI>25, n=132• Continuity of care provider
Weight monitoringShort dietary interventionPsychology assistance when needed
• Reduction in GWG: 7.0 vs 13.8 kg, p<0.0001 Reduction in GDM: 6% vs 29%, p<0.04
Australia
Quinlivan JA et al, Aust NZJ Obstet Gynecol, 2011
• RCT, BMI 20-40, n=401• Low intensity behavioral intervention
One face-to-face visitMailed materialIndividual graphs of weight gain
• Significant reduction in exceeding IOM recommendations: 40.2% vs 52.1%, p=0.003
In normal weight women only! No effect in overweight and obese women
USA
Phelan S et al, Am J Clin Nutr, 2011
The LiP (Lifestyle in Pregnancy) Study: A randomized controlled trial of lifestyle intervention in 360 obese pregnant women
Vinter C, Jensen DM, Ovesen P, Beck-Nielsen H, Jorgensen JS. Diabetes Care, 2011
Ringkjøbing
Ribe
Vejle
Århus
Fyn
BMI > 30
Danish National Board of Health 2012N= 402.955
The LiP (Lifestyle in Pregnancy) Study: A randomized controlled trial of lifestyle intervention in 360 obese pregnant women.
AimTo study the clinical effects of diet
and physical activity during pregnancy
among Danish obese women
InclusionBMI 30-45, age 18-40 years
ExclusionDiabetes, major medical disorders, non
Danish-speaking,
multiple pregnancy, prior serious obstetric
complications including preterm birth
Vinter C, Jensen DM, Ovesen P, Beck-Nielsen H, and Jorgensen JS. Diabetes Care, 2011
Diet
• Individual face-to-face diet counseling sessions 4 times during pregnancy
• Gestational weight gain 5 kilos
Physical activity
• 30-60 min of daily physical activity
• Free membership in fitness center
• Aerobic classes 1 h weekly• Coaching in small groups• Pedometer• Activity calender
Flowchart participation
GA 35 Intervention n=144
Controln=148
P
GWG (kg) 7.0 (4.7-10.6) 8.6 (5.7-11.5) 0.014
GWG < 5 kilos 41 (28.5%) 30 (20.3%) 0.102
GWG < 9 kilos 93 (64.6%) 79 (53.4%) 0.052
Gestational Weight Gain (GWG)
Obstetric and neonatal outcomes
Vinter C et al, Diabetes Care, 2011
What to do?
Strengths and limitations
• Largest RCT among obese pregnant women• Power calculations were based on the expectation of a larger difference in GWG• Detailed follow-up program also among control group ”passive intervention”• Recruiting the most healthy and motivated mothers• LiPO – follow-up on offspring at 3 years of age
PubMed ResultsItems 1 -10 of 10 (Display the 10 citations in PubMed)
• 1. Antenatal interventions for reducing weight in obese women for improving pregnancy outcome. Furber CM, McGowan L, Bower P, Kontopantelis E, Quenby S, Lavender T. Cochrane Database Syst Rev. 2013 Jan 31;1:CD009334. doi: 10.1002/14651858.CD009334.pub2. Review
• 2. Interventions to reduce or prevent obesity in pregnant women: a systematic review. Thangaratinam S, Rogozińska E, Jolly K, Glinkowski S, Duda W, Borowiack E, Roseboom T, Tomlinson J, Walczak J, Kunz R, Mol BW, Coomarasamy A, Khan KS. Health Technol Assess. 2012 Jul;16(31):iii-iv, 1-191. doi: 10.3310/hta16310. Review.
• 3. A systematic review investigating healthy lifestyle interventions incorporating goal setting strategies for preventing excess gestational weight gain. Brown MJ, Sinclair M, Liddle D, Hill AJ, Madden E, Stockdale J. PLoS One. 2012;7(7):e39503. doi: 10.1371/journal.pone.0039503. Epub 2012 Jul 5. Review.
• 4. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Roseboom T, Tomlinson JW, Kunz R, Mol BW, Coomarasamy A, Khan KS. BMJ. 2012 May 16;344:e2088.
• 5. Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis. Oteng-Ntim E, Varma R, Croker H, Poston L, Doyle P. BMC Med. 2012 May 10;10:47. Review.
• 6. Antenatal exercise to improve outcomes in overweight or obese women: A systematic review. Sui Z, Grivell RM, Dodd JM. Acta Obstet Gynecol Scand. 2012 May;91(5):538-45. Epub 2012 Feb 28.
• 7. Antenatal dietary interventions in obese pregnant women to restrict gestational weight gain to Institute of Medicine recommendations: a meta-analysis. Quinlivan JA, Julania S, Lam L. Obstet Gynecol. 2011 Dec;118(6):1395-401. doi: 10.1097/AOG.0b013e3182396bc6. Review.
• 8. Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. Tanentsapf I, Heitmann BL, Adegboye AR. BMC Pregnancy Childbirth. 2011 Oct 26;11:81. doi: 10.1186/1471-2393-11-81. Review
• 9. Behavioural interventions for weight management in pregnancy: a systematic review of quantitative and qualitative data. Campbell F, Johnson M, Messina J, Guillaume L, Goyder E. BMC Public Health. 2011 Jun 22;11:491. doi: 10.1186/1471-2458-11-491. Review.
• 10. Changing diet and physical activity to reduce gestational weight gain: a meta-analysis. Gardner B, Wardle J, Poston L, Croker H. Obes Rev. 2011 Jul;12(7):e602-20. doi: 10.1111/j.1467-789X.2011.00884.x. Epub 2011 Apr 27. Review.
Systematic reviews on intervention
Effects of interventions in pregnancy on maternal weight and obstetric outcomes: metaanalysis of randomised evidence
• BMJ 2012• Study selection: 44 RCT (7278 women)
evaluating any dietary or lifestyle intervention to influence maternal weight and pregnancy outcomes
• Diet – physical activity – mixed approach
Thangaratinam S et al. BMJ 2012
Mean difference in gestational weight gain (kg) with dietary and lifestyle interventions in pregnancy .
Thangaratinam S et al. BMJ 2012;344:bmj.e2088
©2012 by British Medical Journal Publishing Group
Relative risk of effect on size for gestational age with dietary and lifestyle interventions in pregnancy .
Thangaratinam S et al. BMJ 2012;344:bmj.e2088
©2012 by British Medical Journal Publishing Group
Relative risk of effects of weight management interventions in pregnancy on maternal outcomes.
Thangaratinam S et al. BMJ 2012;344:bmj.e2088
Fig 7 Relative risk of effects of weight management interventions in pregnancy on fetal and neonatal outcomes.
Thangaratinam S et al. BMJ 2012;344:bmj.e2088
©2012 by British Medical Journal Publishing Group
Effects of interventions in pregnancy on maternal weight and obstetric outcomes: metaanalysis of randomised evidence
Conclusion:•Dietary and lifestyle intervention in pregnancy are effective in reducing GWG without adverse effect on the risk of SGA•Dietary intervention was associated with the greatest reduction in GWG•Intervention significantly reduced the risk of preeclampsia•Quality of evidence: Moderate for GWG Low for clinical outcomes
Thangaratinam S et al. BMJ 2012
Systematic review of clinical trials on dietary interventions to prevent excessive weight during pregnancy among normal
weight, overweight and obese women
• BMC Pregnancy and childbirth, 2011 • Study selection: 13 RCT (1434 women),
normal weight, overweight and obese women• Evaluating any dietary intervention to
influence maternal weight gain and secondarily child and maternal outcomes
Tanentsapf I et al, BMC Pregnancy and childbirth, 2011
Tanentsapf I et al, BMC Pregnancy and childbirth, 2011
Systematic review of clinical trials on dietary interventions to prevent excessive weight during pregnancy among normal
weight, overweight and obese women
Conclusion:•Dietary intervention in pregnancy are effective in decreasing GWG, but not preventing excessive GWG (IOM).•No significant difference in weight retention 6 weeks postpartum, but at 6 months postpartum•Dietary intervention had no significant effect on birthweight or maternal outcomes•Low methodological quality of included studies
Tanentsapf I et al, BMC Pregnancy and childbirth, 2011
Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review
and meta-analysis
• BMC Medicine, 2012• Study selection: 13 RCT , 6 non-RCT,
overweight and obese women (excluding NW only)
• Evaluating any antenatal dietary, activity, behavior or lifestyle intervention to improve maternal and perinatal outcomes
Oteng-Ntim E et al, BMC Medicine, 2012
Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on gestational weight gain
(kg).
Oteng-Ntim E et al, BMC Medicine, 2012
Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on risk of gestational
diabetes.
Oteng-Ntim E et al, BMC Medicine, 2012
Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review
and meta-analysis
Conclusion:•Antenatal intervention in overweight and obese pregnant women is associated with restricted GWG •A trend towards a reduction in GDM•Studies of low to medium quality - findings should be interpreted with caution•Further metaanalysis not needed•Large-scale well-designed prospective trials
Oteng-Ntim E et al, BMC Medicine, 2012
Overall conclusion
• Lifestyle intervention restricts gestational weight gain• Conflicting results on the effect on maternal and neonatal outcomes• No major adverse effect (stillbirth, SGA)• Level of evidence is low• Long-term maternal and offspring follow-up is needed
Interpregnancy weight change and risk of adversepregnancy outcomes: a population-based study
Adjusted odds ratios for adverse pregnancy outcomes for those who gained 3 or more BMI units (~10 kg) during an average of 2 years
– Pre-eclampsia 1.78 (95% CI 1.52–2.08)– Gestational hypertension 1.76 (1.39–2.23)– Gestational diabetes 2.09 (1.68–2.61)– Caesarean delivery 1.32 (1.22–1.44)– Stillbirth 1.63 (1.20–2.21) – LGA infants 1.87 (1.72–2.04)
Eduardo Villamor, Sven Cnattingius, Lancet 2006
Weight loss before conception: A systematic literature review
”Is there scientific evidence for positive health effects of weight loss prior to conception for overweight and obese women?”
Glazer et al, Epidemiology, 2004 (n=4000) Villamor and Cnattingius, Lancet, 2006 (n=150.000)
•4.5 kg weight loss between pregnancies reduced the risk of gestational diabetes•Women with BMI > 25 in first pregnancy had decreased risk of LGA infants with weight loss > 1 BMI unit•Lack of studies investigating the effect of dietary induced intervention before pregnancy!
Forsum E. et al, Food and Nutrition Research, 2013
Research gap
Lack of
Evidence
Public Health Priority
Ongoing studies
TOP study, DenmarkFit for Delivery, NorwayETIP, NorwayLIMIT, AustraliaSPRING, AustraliaHealthy Moms, USAMOM trial, Canada………………….
"Effects of weight management interventions on
maternal and fetal outcomes in pregnancy: Individual
patient data (IPD) meta-analysis of randomised trials
and model based economic evaluation (iWIP)"
Women's Health Research UnitCentre for Primary Care and Public Health
Blizard InstituteBarts and The London School of Medicine and Dentistry
Project’s overview
• Maternal obesity and excess weight gain in pregnancy are associated with maternal and fetal complications in
pregnancy and in the long term.
• HTA report published in 2012 (Thangaratinam et al. 2012) on diet and lifestyle interventions showed that weight
management interventions in pregnancy are effective in reducing maternal weight gain compared to standard
care, with diet based interventions most effective.
• The findings were based published studies. However, the effects of weight management interventions in women with
varied pre pregnancy weight, ethnicity, age and socioeconomic status was difficult to ascertain. Furthermore, the
relationship between the amount of weight change in pregnancy and risk of maternal and fetal complications was not
known.
• To address the above gaps in evidence, project team have established a Collaborative Network of researchers who
have conducted studies on weight management interventions in pregnancy. As to the date The Network has access to
around 5000 individual patient data from 16 datasets.
• By pooling the individual data together, we will be able to estimate with increased confidence, the differential effects if
any of the weight management interventions in various groups, allowing us to target the population that needs the
most support for a beneficial outcome. It will also generate recommendations on optimal weight gain in pregnancy to
minimise maternal and fetal complications and the cost effectiveness of these interventions.
Project’s objectives and design
MAIN OBJECTIVES:
The primary objective will be to determine the differential effects of weight
management interventions in pregnancy by:
i) BMI ii) age iii) ethnicity iv) parity and v) physical and mental medical
conditions like diabetes and depression on:
a) maternal weight gain and
b) composite pregnancy outcome of maternal and fetal complications.
DESIGN: Individual patient data (IPD) meta analysis of randomised trials
Contact details
Project Lead: Professor Shakila Thangaratinam s.thangaratinam@qmul.ac.uk
Project’s Co-ordinator: Ms Ewelina Rogozinska e.a.rogozinska@qmul.ac.uk
Project’s details
http://blizard.qmul.ac.uk/research-dissemination/756-iwip.html
Future perspectives
• Should interventions be considered prepregnant to be able to alter short term obstetric and neonatal outcomes?• Nature, duration and intensity of such intervention? • Further research is necessary to identify such interventions and what benefits these confer on health and wellbeing in later life clinical implication and implementation
Thank you for the attention!
christina.vinter@rsyd.dk
top related