Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial

Rethinking causal assumptions about maternal BMI, gestational weight gain, and adverse pregnancy outcomes

BACKGROUND

The aim of this study was to evaluate commonly assumed causal relationships between body mass index (BMI), gestational weight gain (GWG), and adverse pregnancy outcomes, which have formed the basis of guidelines and interventions aimed at limiting GWG in women with overweight or obesity. We explored relationships between maternal BMI, total GWG (as a continuous variable and as 'excessive' GWG), and pregnancy outcomes (including infant birthweight measures and caesarean birth).

METHODS

Analysis of individual participant data (IPD) from the i-WIP (International Weight Management in Pregnancy) Collaboration, from randomised trials of diet and/or physical activity interventions during pregnancy reporting GWG and maternal and neonatal outcomes. Women randomised to the control arm of 20 eligible randomised trials (4370 of 8908 participants) from the i-WIP dataset of 36 randomised trials (total 12,240 women). The main research questions were to characterise the relationship between maternal BMI and (a) total GWG, (b) the risk of 'excessive' GWG (using the Institute of Medicine's guidelines), and (c) adverse pregnancy outcomes as mediated via GWG versus other pathways to determine the extent to which the observed effect of maternal BMI on pregnancy outcomes is mediated via GWG. We utilised generalised linear models and regression-based mediation analyses within an IPD meta-analysis framework.

RESULTS

Mean GWG decreased linearly as maternal BMI increased; however, the risk of 'excessive' GWG increased markedly at BMI category thresholds (i.e. between the normal and overweight BMI category threshold and between the overweight and obese BMI category threshold). Increasing maternal BMI was associated with increased risk of all pregnancy outcomes assessed; however, there was no evidence that this effect was mediated via effects on GWG.

CONCLUSIONS

There is evidence of a meaningful relationship between maternal BMI and GWG and between maternal BMI and adverse pregnancy outcomes. There is no evidence that the effect of maternal BMI on outcomes is via an effect on GWG. Our analyses also cast doubt on the existence of a relationship between 'excessive' GWG and adverse pregnancy outcomes. Our findings challenge the practice of actively managing GWG throughout pregnancy.

Associations of Maternal Educational Level, Proximity to Green Space During Pregnancy, and Gestational Diabetes With Body Mass Index From Infancy to Early Adulthood: A Proof-of-Concept Federated Analysis in 18 Birth Cohorts

International sharing of cohort data for research is important and challenging. We explored the feasibility of multicohort federated analyses by examining associations between 3 pregnancy exposures (maternal education, exposure to green vegetation, and gestational diabetes) and offspring body mass index (BMI) from infancy to age 17 years. We used data from 18 cohorts (n = 206,180 mother-child pairs) from the EU Child Cohort Network and derived BMI at ages 0-1, 2-3, 4-7, 8-13, and 14-17 years. Associations were estimated using linear regression via 1-stage individual participant data meta-analysis using DataSHIELD. Associations between lower maternal education and higher child BMI emerged from age 4 and increased with age (difference in BMI z score comparing low with high education, at age 2-3 years = 0.03 (95% confidence interval (CI): 0.00, 0.05), at 4-7 years = 0.16 (95% CI: 0.14, 0.17), and at 8-13 years = 0.24 (95% CI: 0.22, 0.26)). Gestational diabetes was positively associated with BMI from age 8 years (BMI z score difference = 0.18, 95% CI: 0.12, 0.25) but not at younger ages; however, associations attenuated towards the null when restricted to cohorts that measured gestational diabetes via universal screening. Exposure to green vegetation was weakly associated with higher BMI up to age 1 year but not at older ages. Opportunities of cross-cohort federated analyses are discussed.

Higher early pregnancy plasma myo-inositol associates with increased postprandial glycaemia later in pregnancy: Secondary analyses of the NiPPeR randomized controlled trial

AIM

Myo-inositol supplementation from ~13 weeks' gestation reportedly improves glycaemia regulation in metabolically at-risk women, with speculation that earlier supplementation might bring further improvement. However, the NiPPeR trial of a myo-inositol-containing supplement starting preconception did not lower gestational glycaemia in generally healthy women. We postulated that the earlier timing of supplementation influences the maternal metabolic adaptation for gestational glycaemia regulation.

METHODS

In total, 585 women were recruited from Singapore, UK and New Zealand for the NiPPeR study. We examined associations of plasma myo-inositol concentrations at 7 and 28 weeks' gestation with 28 weeks plasma glucose (PG; fasting, and 1 h and 2 h in 75 g oral glucose tolerance test) and insulin indices using linear regression adjusting for covariates.

RESULTS

Higher 7-week myo-inositol, but not 28-week myo-inositol, associated with higher 1 h PG [βadj (95% confidence intervals) 0.05 (0.01, 0.09) loge mmol/L per loge μmol/L, p = .022] and 2 h PG [0.08 (0.03, 0.12), p = .001]; equivalent to 0.39 mmol/L increase in 2 h PG for an average 7-week myo-inositol increase of 23.4 μmol/L with myo-inositol supplementation. Higher 7-week myo-inositol associated with a lower 28-week Stumvoll index (first phase), an approximation of insulin secretion [-0.08 (-0.15, -0.01), p = .020] but not with 28-week Matsuda insulin sensitivity index. However, the clinical significance of a 7-week myo-inositol-related increase in glycaemia was limited as there was no association with gestational diabetes risk, birthweight and cord C-peptide levels. In-silico modelling found higher 28-week myo-inositol was associated with lower gestational glycaemia in White, but not Asian, women after controlling for 7-week myo-inositol effects.

CONCLUSION

To our knowledge, our study provides the first evidence that increasing first trimester plasma myo-inositol may slightly exacerbate later pregnancy post-challenge glycaemia, indicating that the optimal timing for starting prenatal myo-inositol supplementation needs further investigation.

Association of child weight with attendance at a healthy lifestyle service among women with obesity during pregnancy

Women with obesity during pregnancy are at increased risk of excessive gestational weight gain (GWG) and other maternal and infant adverse outcomes, which all potentially increase childhood obesity. This study explored infant weight outcomes for women with a body mass index (BMI) ≥ 35 kg/m² who were offered an antenatal healthy lifestyle service. A retrospective cohort study, including linking data from two separate health care Trusts, was undertaken. Data were collected from maternity records for women with a BMI ≥ 35 kg/m2 referred to an antenatal healthy lifestyle service from 2009 to 2015. The respective child's weight outcome data was additionally collected from health and National Child Measurement Programme records. Univariate logistic regression determined the odds of childhood overweight, obesity and severe obesity according to attendance at the antenatal healthy lifestyle service, GWG and sociodemographic characteristics. Factors significant (p < 0.05) within the univariate analysis were entered into multiple logistic regression models. Among women with a BMI ≥ 35 kg/m², 30.4% of their children were obese at school entry and 13.3% severely obese. Healthy lifestyle service attendance was not associated with childhood overweight or obesity at any point within the univariate analysis. At school age multiple regression analysis showed the odds of overweight and obesity increased with excessive GWG and the odds of obesity decreased with a parent in a professional occupation, additionally having a mother who smoked in pregnancy increased severe obesity. Women should be supported to optimise their BMI before pregnancy. Additionally, rather than exclusively focusing on changing an individual's behaviour, future interventions should consider external influences such as the woman's family, friends and sociodemographic background.

Neurodevelopmental Programming of Adiposity: Contributions to Obesity Risk

This review analyzes the published evidence regarding maternal factors that influence the developmental programming of long-term adiposity in humans and animals via the central nervous system (CNS). We describe the physiological outcomes of perinatal underfeeding and overfeeding and explore potential mechanisms that may mediate the impact of such exposures on the development of feeding circuits within the CNS-including the influences of metabolic hormones and epigenetic changes. The perinatal environment, reflective of maternal nutritional status, contributes to the programming of offspring adiposity. The in utero and early postnatal periods represent critically sensitive developmental windows during which the hormonal and metabolic milieu affects the maturation of the hypothalamus. Maternal hyperglycemia is associated with increased transfer of glucose to the fetus driving fetal hyperinsulinemia. Elevated fetal insulin causes increased adiposity and consequently higher fetal circulating leptin concentration. Mechanistic studies in animal models indicate important roles of leptin and insulin in central and peripheral programming of adiposity, and suggest that optimal concentrations of these hormones are critical during early life. Additionally, the environmental milieu during development may be conveyed to progeny through epigenetic marks and these can potentially be vertically transmitted to subsequent generations. Thus, nutritional and metabolic/endocrine signals during perinatal development can have lifelong (and possibly multigenerational) impacts on offspring body weight regulation.

Fetal Growth and Adiposity of Infants Born Large for Gestational Age in Three Harmonized Randomized Trials

OBJECTIVE

 Infants born large for gestational age (LGA) are at an increased risk of short- and longer-term adverse outcomes. Understanding fetal growth and adiposity and their trajectories may help inform interventions to prevent birth of LGA infants. We aimed to compare fetal growth and adiposity measures of infants born LGA with those born not LGA, to determine whether the discrepancy at birth was primarily due to larger size throughout gestation, or instead to different trajectories of fetal growth.

STUDY DESIGN

 This was a secondary analysis of secondary outcomes of fetal growth and adiposity from three harmonized randomized trials-the LIMIT, GRoW, and Optimise randomized trials. These trials recruited women in early pregnancy, and a singleton gestation, from three major public metropolitan Adelaide maternity hospitals. Maternal body mass index (BMI) ranged from 18.5 to ≥40.0 kg/m2. Data were obtained from enrolled women who underwent research ultrasounds at 28 and 36 weeks' gestation. Outcome measures were ultrasound measures of fetal biometry and adiposity.

RESULTS

 Infants born LGA had larger fetal biometry measures, and higher growth trajectories, from 20 weeks' gestation. Fetal adiposity measures were consistently larger among infants born LGA and these differences increased over time. We did not find evidence that the differences in biometry and adiposity measurements varied according to maternal BMI.

CONCLUSION

 Infants born LGA had larger fetal biometry measures at all time points from 20 weeks' gestation, compared with infants born not LGA suggesting any interventions to prevent LGA likely need to commence earlier in pregnancy or prior to conception.

KEY POINTS

· Infants born LGA had larger fetal biometry measures from 20 weeks' gestation.. · Infants born LGA had larger fetal adiposity measures.. · Interventions to prevent LGA need to start earlier in pregnancy or prior to conception..

Feasibility of Telehealth and Innovative Technologies to Limit Excessive Gestational Weight Gain

OBJECTIVE

To test the feasibility of using telehealth to deliver nutritional counseling by tracking gestational weight gain remotely using Bluetooth weight scales.

DESIGN

Quasi-experimental feasibility study.

SETTING

One-on-one nutritional counseling was conducted remotely via a telehealth platform using a registered dietitian.

PARTICIPANTS

Twenty-nine pregnant individuals ages 18 years or older, between 12 and 27 weeks' gestation, with a prepregnancy body mass index of ≥30 kg/m2, singleton fetus, and English proficiency were recruited for the study. Among the 29 potential participants, 20 completed the initial survey and met the criteria; 11 completed the study.

METHODS

This study tested the feasibility of using telehealth to deliver nutritional counseling for 30 minutes, once a week, for 6 weeks. Self-weighing was tracked through a preconfigured Bluetooth scale given to study participants that enabled weight data to be automatically uploaded each time the scale was used.

RESULTS

Among the 11 study participants receiving Bluetooth scales, adherence to self-weighing was high (81%). All five participants randomized to nutritional counseling found that telehealth visits with a registered dietitian were easy to use and helpful. Although participants who received nutritional counseling gained 2.5 lb less than those who did not receive nutritional counseling (p = .523), there was no significant difference between the intervention group and historical control individuals (p = .716).

CONCLUSION

Incorporating telehealth for nutrition counseling and accurate remote weight data collection may be part of a comprehensive strategy to address gestational weight gain in high-risk pregnant populations. Further research with larger samples is needed.

A retrospective comparative study of antenatal healthy lifestyle service interventions for women with a raised body mass index

BACKGROUND

Women with obesity are more likely to gain excessive gestational weight; with both obesity and excessive weight gain linked to adverse outcomes for mothers and their infant. Provision of antenatal healthy lifestyle services is currently variable, with uncertainty over the most effective gestational healthy lifestyle interventions.

AIM

To compare pregnancy and birth outcomes among women who experienced an antenatal health lifestyle service with a cohort who did not receive this service.

METHODS

A retrospective comparative cohort study was undertaken in women with a BMI ≥ 40 kg/m² attending maternity care in two NHS Trusts. One Trust provided an antenatal healthy lifestyle service, while the comparison Trust provided routine maternity care. Data was collected from medical records.

FINDINGS

No differences were observed between the antenatal healthy lifestyle service and comparison cohorts for average gestational weight gain [adjusted mean difference (aMD) - 0.70 kg (95%CI -2.33, 0.93)], rate of weight gain [aMD - 0.02 kg/week (95%CI -0.08, 0.04)] or weight gain in accordance with recommendations. The proportion of women breastfeeding at discharge was higher for the antenatal healthy lifestyle service than the comparison cohort (42.4% vs 29.8%). No other clinical outcomes were enhanced with the antenatal healthy lifestyle service.

CONCLUSION

Internal audit had suggested the antenatal healthy lifestyle service was successful at managing gestational weight gain in women with a BMI ≥ 40 kg/m². However, no benefit on gestational weight gain was evident once the service was evaluated against a comparison cohort with adequate adjustment for confounders. It is essential that future services are evaluated against a relevant comparison group.

Effects of mHealth-Based Lifestyle Interventions on Gestational Diabetes Mellitus in Pregnant Women With Overweight and Obesity: Systematic Review and Meta-Analysis

BACKGROUND

The increasing incidence of gestational diabetes mellitus (GDM) is a global health problem that is more likely to occur in pregnant women with overweight or obesity. Adhering to a healthy lifestyle is associated with a reduced risk of GDM. With the development of IT, mobile health (mHealth) interventions have become widely available in health care. However, there are no definitive conclusions on the effectiveness of mHealth-based lifestyle interventions in preventing GDM.

OBJECTIVE

This study aims to evaluate the impact of mHealth-based lifestyle interventions on GDM and other pregnancy outcomes in pregnant women with overweight or obesity.

METHODS

A systematic literature search was conducted in 5 English databases (MEDLINE, Embase, Web of Science, CENTRAL, and CINAHL) and 4 Chinese databases (CBM, CNKI, Vip, and Wanfang) to identify randomized controlled trials (RCTs) on the effectiveness of mHealth-based interventions for GDM from inception to January 10, 2023. In total, 2 authors independently screened the studies and extracted the data. The quality of the included studies was examined using the Cochrane risk-of-bias tool. Data synthesis was conducted using Review Manager (version 5.4; The Cochrane Collaboration).

RESULTS

A total of 16 RCTs with 7351 participants were included in this study. The included studies were published between 2014 and 2021 and were conducted in China, the United States, Australia, New Zealand, the United Kingdom, Ireland, and Norway. The sample sizes of the studies ranged from 75 to 2202, and the duration of the mHealth-based lifestyle interventions ranged from 4 to 28 weeks. Compared with usual care, mHealth-based lifestyle interventions significantly reduced the incidence of GDM (odds ratio [OR] 0.74, 95% CI 0.56-0.96; P=.03; I2=65%), preterm birth (OR 0.65, 95% CI 0.48-0.87; P=.004; I2=25%), macrosomia (OR 0.59, 95% CI 0.40-0.87; P=.008; I2=59%), and gestational weight gain (mean difference=-1.12 kg, 95% CI -1.44 to -0.80; P<.001; I2=43%). The subgroup analysis showed that interventions delivered via apps (OR 0.55, 95% CI 0.37-0.83; P=.004; I2=44%), provided by obstetricians (OR 0.69, 95% CI 0.51-0.93; P=.02; I2=60%), and targeted at Asian populations (OR 0.44, 95% CI 0.34-0.58; P<.001; I2=0%) and that used the International Association of Diabetes and Pregnancy Study Groups diagnostic criteria (OR 0.58, 95% CI 0.39-0.86; P=.007; I2=69%) showed a statistically significant reduction in the risk of GDM.

CONCLUSIONS

mHealth-based lifestyle interventions had a favorable impact on the prevention of GDM in pregnant women with overweight and obesity. Future studies need to further explore the potential of mHealth-based interventions for GDM through better design and more rigorous large-scale RCTs.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021286995; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=286995.

Effects of an antenatal dietary intervention in women with obesity or overweight on child outcomes at 8-10 years of age: LIMIT randomised trial follow-up

BACKGROUND

The LIMIT randomised controlled trial looked at the effect of a dietary and lifestyle intervention compared with routine antenatal care for pregnant women with overweight and obesity on pregnancy outcomes. While women in the intervention group improved diet and physical activity with a reduction of high birth weight, other outcomes were similar. We have followed the children born to women in this study at birth, 6 and 18 months and 3-5 years of age and now report follow-up of children at 8-10 years of age.

METHODS

Children at 8-10 years of age who were born to women who participated in the LIMIT randomised trial, and whose mother provided consent to ongoing follow-up were eligible for inclusion. The primary study endpoint was the incidence of child BMI z-score > 85th centile for child sex and age. Secondary study outcomes included a range of anthropometric measures, neurodevelopment, child dietary intake, and physical activity. Analyses used intention to treat principles according to the treatment group allocated in pregnancy. Outcome assessors were blinded to the allocated treatment group.

RESULTS

We assessed 1,015 (Lifestyle Advice n = 510; Standard Care n = 505) (48%) of the 2,121 eligible children. BMI z-score > 85th percentile was similar for children of women in the dietary Lifestyle Advice Group compared with children of women in the Standard Care Group (Lifestyle Advice 479 (45%) versus Standard Care 507 (48%); adjusted RR (aRR) 0.93; 95% CI 0.82 to 1.06; p = 0.302) as were secondary outcomes. We observed that more than 45% of all the children had a BMI z-score > 85th percentile, consistent with findings from follow-up at earlier time-points, indicating an ongoing risk of overweight and obesity.

CONCLUSIONS

Dietary and lifestyle advice for women with overweight and obesity in pregnancy has not reduced the risk of childhood obesity, with children remaining at risk of adolescent and adult obesity. Other strategies are needed to address the risk of overweight and obesity in children including investigation of preconception interventions to assess whether this can modify the effects of maternal pre-pregnancy BMI. The LIMIT randomised controlled trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Effectiveness of pre-pregnancy lifestyle in preventing gestational diabetes mellitus-a systematic review and meta-analysis of 257,876 pregnancies

BACKGROUND

Gestational Diabetes Mellitus (GDM) is hyperglycaemia first detected during pregnancy. Globally, GDM affects around 1 in 6 live births (up to 1 in 4 in low- and middle-income countries- LMICs), thus, urgent measures are needed to prevent this public health threat.

OBJECTIVE

To determine the effectiveness of pre-pregnancy lifestyle in preventing GDM.

METHODS

We searched MEDLINE, Web of science, Embase and Cochrane central register of controlled trials. Randomized control trials (RCTs), case-control studies, and cohort studies that assessed the effect of pre-pregnancy lifestyle (diet and/or physical activity based) in preventing GDM were included. Random effects model was used to calculate odds ratio (OR) with 95% confidence interval. The Cochrane ROB-2 and the Newcastle-Ottawa Scale were used for assessing the risk of bias. The protocol was registered in PROSPERO (ID: CRD42020189574) RESULTS: Database search identified 7935 studies, of which 30 studies with 257,876 pregnancies were included. Meta-analysis of the RCTs (N = 5; n = 2471) in women who received pre-pregnancy lifestyle intervention showed non-significant reduction of the risk of developing GDM (OR 0.76, 95% CI: 0.50-1.17, p = 0.21). Meta-analysis of cohort studies showed that women who were physically active pre-pregnancy (N = 4; n = 23263), those who followed a low carbohydrate/low sugar diet (N = 4; n = 25739) and those women with higher quality diet scores were 29%, 14% and 28% less likely to develop GDM respectively (OR 0.71, 95% CI: 0.57, 0.88, p = 0.002, OR 0.86, 95% CI: 0.68, 1.09, p = 0.22 and OR 0.72, 95% CI 0.60-0.87, p = 0.0006).

CONCLUSION

This study highlights that some components of pre-pregnancy lifestyle interventions/exposures such as diet/physical activity-based preparation/counseling, intake of vegetables, fruits, low carbohydrate/low sugar diet, higher quality diet scores and high physical activity can reduce the risk of developing gestational diabetes. Evidence from RCTs globally and the number of studies in LMICs are limited, highlighting the need for carefully designed RCTs that combine the different aspects of the lifestyle and are personalized to achieve better clinical and cost effectiveness.

Effectiveness of Lifestyle Interventions during Pregnancy on Preventing Gestational Diabetes Mellitus in High-Risk Women: A Systematic Review and Meta-Analyses of Published RCTs

BACKGROUND

Until now, it is uncertain whether lifestyle interventions during pregnancy can prevent gestational diabetes mellites (GDM) in high-risk pregnant women.

OBJECTIVE

This study aims at investigating the effectiveness of dietary interventions and/or exercise interventions during pregnancy for preventing GDM in high-risk pregnant women.

MATERIALS AND METHODS

Eligible randomized controlled trials (RCTs) were selected after a search in CENTRAL, Scopus, and PubMed. Synthesis was performed for the outcome of GDM in women with any identified GDM risk factor. Separate meta-analyses (MA) were performed to assess the efficacy of either nutrition or physical activity (PA) interventions or both combined compared with standard prenatal care for preventing GDM. Subgroup and sensitivity analyses, as well as meta-regressions against OR, were performed to assess potentional heterogeneity. Overall quality, the quality of RCTs, and publication bias were also evaluated.

RESULTS

A total of 13,524 participants comprising high-risk pregnant women in 41 eligible RCTs were analyzed for GDM. Women receiving only a nutrition intervention during pregnancy were less likely to experience GDM compared with women following standard prenatal care. Among 3109 high-risk pregnant women undergoing only dietary intervention for preventing GDM, 553 (17.8%) developed GDM; however, the result of the MA was marginally not significant (OR 0.73, 95%CI 0.51, 1.03; p-value 0.07), (Q 21.29, p-value 0.01; I2 58% (95%CI 10, 78%)). Subgroup analyses demonstrated an effect for studies that were conducted in Great Britain (OR 0.65, 95%CI 0.49, 0.81; p-value 0.003), and in Spain (OR 0.50, 95%CI 0.27, 0.94; p-value 0.03), for studies with forms of the Mediterranean diet as the intervention's component (OR 0.61; 95%CI 0.46, 0.81; p-value 0.0005), and for studies including a motivation arm in the intervention (OR 0.71, 95%CI 0.58, 0.87; p-value 0.0008). Among 2742 high-risk pregnant women being analyzed for GDM outcome after receiving only an exercise intervention, 461 (16.8%) were diagnosed with GDM. Women after receiving PA intervention were less likely to develop GDM (OR 0.64, 95%CI 0.51, 0.80; p-value < 0.0001), (Q 11.27, p-value 0.51; I2 0% (95%CI 0, 99%)). Finally, 1308 (17%) cases of GDM were diagnosed among 7673 high-risk pregnant women undergoing both diet and PA intervention. Women in the group of mixed lifestyle intervention had a significant reduction in incidence of GDM (OR 0.70, 95%CI 0.55, 0.90; p-value 0.005), (Q 50.32, p-value < 0.0001, I2 66%, (95% CI 44, 79%)).

CONCLUSIONS

The results of this study support the efficacy of lifestyle interventions during pregnancy for preventing GDM in high-risk women if an exercise component is included in the intervention arm, either alone, or combined with diet. A combined lifestyle intervention including physical exercise and a Mediterranean diet accompanied by motivation support may be considered the most effective way to prevent GDM among high-risk women during pregnancy. Future research is needed to strengthen these findings.

The effects of exercise intervention on complications and pregnancy outcomes in pregnant women with overweight or obesity: A systematic review and meta-analysis

BACKGROUND

Being overweight or obese is closely related to adverse pregnancy outcomes and harms both pregnant women and neonates, increasing complications during pregnancy and leading to adverse pregnancy outcomes. Consequently, a meta-analysis was done to investigate exercise therapy impact on the complications and outcomes of pregnant women who are obese or overweight.

MATERIALS AND METHODS

The computer system searched PubMed, Cochrane Library, Wanfang, EMBASE, and CNKI databases. The search duration extended from the database establishment until October 2022. A thorough search was carried out for pertinent studies investigating exercise therapy impact on pregnancy complications and outcomes in obese or overweight pregnant women. The heterogeneity test was carried out using Cochrane Q and Chi-square tests. The combined findings from the meta-analysis were examined for reliability and robustness using sensitivity and publication bias analyses. All statistics used RevMan 5.3 software.

RESULTS

This meta-analysis included data from 8026 patients from 22 randomized controlled trials. The results demonstrated that exercise therapy might successfully decrease the incidence of gestational diabetes mellitus (GDM) (odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.74-0.96, P = .01) and macrosomia (OR = 0.78, 95% CI: 0.68-0.89, P < .001), and control weight gain during pregnancy (SMD = -0.2, 95% CI: -0.31 to -0.08, P < .001).

CONCLUSIONS

Exercise therapy can control weight gain during pregnancy, lower the incidence of GDM and the macrosomia rate, and improve adverse pregnancy outcomes.

Maternal obesity: A potential disruptor of female fertility and current interventions to reduce associated risks

Currently, obesity has achieved epidemic levels in reproductive-aged women with a myriad of consequences. Obesity is susceptible to several reproductive complications that eventually affect fertility rates. These complications originate from the deteriorated quality of oocytes from mothers with obesity, which increases the probability of chromosomal aneuploidy, elevated reactive oxygen species production, compromised embryonic developmental competency, and eventually reduced fertility. Maternal obesity is linked to pregnancy complications such as implantation error, abortion, miscarriage, and early pregnancy loss. This review highlights the adverse effects of maternal obesity on female fertility, with a focus on the mechanistic link between maternal obesity and oocyte quality and discusses possible measures to reduce its associated risks.

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

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

Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview

Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality. It is important to distinguish between pre-existing (chronic) hypertension and gestational hypertension, developing after 20 weeks of gestation and usually resolving within 6 weeks postpartum. There is a consensus that systolic blood pressure ≥ 170 or diastolic blood pressure ≥ 110 mmHg is an emergency and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. The current European guidelines recommend initiating drug treatment in pregnant women with persistent elevation of blood pressure ≥ 150/95 mmHg and at values > 140/90 mmHg in women with gestational hypertension (with or without proteinuria), with pre-existing hypertension with the superimposition of gestational hypertension, and with hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice. The results of the CHIPS and CHAP studies are likely to reduce the threshold for initiating treatment. Women with a history of hypertensive disorders in pregnancy, particularly those with pre-eclampsia, are at high risk of developing cardiovascular disease later in life. Obstetric history should become a part of the cardiovascular risk assessment in women.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review

Importance

Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified.

Objective

To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care.

Data Sources

Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020.

Study Selection

Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included.

Data Extraction and Synthesis

Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers.

Main Outcomes and Measures

The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care).

Results

Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG.

Conclusions and Relevance

These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

Calorie restriction and pravastatin administration during pregnancy in obese rhesus macaques modulates maternal and infant metabolism and infant brain and behavioral development

Background

Maternal obesity has been associated with a higher risk of pregnancy-related complications in mothers and offspring; however, effective interventions have not yet been developed. We tested two interventions, calorie restriction and pravastatin administration, during pregnancy in a rhesus macaque model with the hypothesis that these interventions would normalize metabolic dysregulation in pregnant mothers leading to an improvement in infant metabolic and cognitive/social development.

Methods

A total of 19 obese mothers were assigned to either one of the two intervention groups (n = 5 for calorie restriction; n = 7 for pravastatin) or an obese control group (n = 7) with no intervention, and maternal gestational samples and postnatal infant samples were compared with lean control mothers (n = 6) using metabolomics methods.

Results

Gestational calorie restriction normalized one-carbon metabolism dysregulation in obese mothers, but altered energy metabolism in her offspring. Although administration of pravastatin during pregnancy tended to normalize blood cholesterol in the mothers, it potentially impacted the gut microbiome and kidney function of their offspring. In the offspring, both calorie restriction and pravastatin administration during pregnancy tended to normalize the activity of AMPK in the brain at 6 months, and while results of the Visual Paired-Comparison test, which measures infant recognition memory, was not significantly impacted by either of the interventions, gestational pravastatin administration, but not calorie restriction, tended to normalize anxiety assessed by the Human Intruder test.

Conclusions

Although the two interventions tested in a non-human primate model led to some improvements in metabolism and/or infant brain development, negative impacts were also found in both mothers and infants. Our study emphasizes the importance of assessing gestational interventions for maternal obesity on both maternal and offspring long-term outcomes.

Short-term neonatal outcomes of pregnancies complicated by maternal obesity

BACKGROUND

Maternal obesity complicates a high number of pregnancies. The degree to which neonatal outcomes are adversely affected is unclear.

OBJECTIVE

This study aimed to evaluate neonatal outcomes of pregnancies complicated by maternal obesity.

STUDY DESIGN

This study was a secondary analysis of a cohort of deliveries occurring on randomly selected days at 25 hospitals from 2008 to 2011. Data were collected by certified abstractors. This analysis included singleton deliveries between 24 and 42 weeks of gestation. Body mass index was calculated on the basis of maternal height and most recent weight before delivery. Normal and overweight (reference group; body mass index, 18.5-29.9 kg/m2), obese (body mass index, 30.0-39.9 kg/m2), morbidly obese (body mass index, 40.0-49.9 kg/m2), and super morbidly obese (body mass index, ≥50 kg/m2) patients were compared. Patients in the reference group were matched in a 1:1 ratio with those in all other groups with obesity using the baseline characteristics of age, race and ethnicity, previous cesarean delivery, preexisting diabetes mellitus, chronic hypertension, parity, cigarette use, and insurance status. The primary outcome was composite neonatal morbidity, including fetal or neonatal death, hypoxic-ischemic encephalopathy, respiratory distress syndrome, intraventricular hemorrhage grade 3 or 4, necrotizing enterocolitis, sepsis, birth injury, seizures, or ventilator use. We used a modified Poisson regression to examine the associations between body mass index and composite neonatal outcome. Preterm delivery at <37 weeks of gestation and the presence of maternal preeclampsia or eclampsia were included in the final model because of their known associations with neonatal outcomes.

RESULTS

Overall, 52,162 patients and their neonates were included after propensity score matching. Of these, 21,704 (41.6%) were obese, 3787 (7.3%) were morbidly obese, and 590 (1.1%) were super morbidly obese. A total of 2103 neonates (4.0%) had the composite outcome. Neonates born to pregnant people with morbid obesity had a 33% increased risk of composite neonatal morbidity compared with those in the reference group (adjusted odds ratio, 1.33; 95% confidence interval, 1.17-1.52), but no significant association was observed for persons with obesity (adjusted odds ratio, 1.05; 95% confidence interval, 0.97-1.14) or with super morbid obesity (adjusted odds ratio, 1.18; 95% confidence interval, 0.86-1.64).

CONCLUSION

Compared with the reference group, gravidas with morbid obesity were at higher risk of composite neonatal morbidity.

Impact of BMI and smoking in adolescence and at the start of pregnancy on birth weight

BACKGROUND

Birth weight is an indicator of intra-uterine conditions but also a determinant for future health. The importance of preconception health for a healthy birth weight has been emphasized, but evidence is lacking on how modifiable factors in adolescence, such as body mass index (BMI) and smoking, affect future pregnancy outcome. We evaluated associations between BMI and smoking in adolescence and at the start of pregnancy and birth weight of the first-born child.

METHODS

This longitudinal study included 1256 mothers, born 1962-1992, and their first-born children, born between 1982-2016. Self-reported questionnaire information on weight, height and smoking at age 19 was cross-linked with national register data obtained at the start of pregnancy and with the birth weights of the children. Univariable and multivariable linear regressions were performed to determine the impact of maternal factors at 19 years of age and at the start of the pregnancy respectively, and the importance of BMI status at these points of time for the birth weight of the first child.

RESULTS

BMI and smoking at the start of the pregnancy displayed strong associations with birth weight in a multivariable analysis, BMI with a positive association of 14.9 g per BMI unit (95% CI 6.0; 23.8 p = 0.001) and smoking with a negative association of 180.5 g (95% CI -275.7; -85.4) p = 0.0002). Smoking and BMI at 19 years of age did not show this association. Maternal birth weight showed significant associations in models at both time-points. Becoming overweight between age 19 and the start of the pregnancy was associated with a significantly higher birth weight (144.6 (95% CI 70.7;218.5) p = 0.0002) compared to mothers with normal weight at both time points.

CONCLUSIONS

Our findings indicate that the time period between adolescence and first pregnancy could be a window of opportunity for targeted health promotion to prevent intergenerational transmission of obesity.

Data processing choices can affect findings in differential methylation analyses: an investigation using data from the LIMIT RCT

Objective

A wide array of methods exist for processing and analysing DNA methylation data. We aimed to perform a systematic comparison of the behaviour of these methods, using cord blood DNAm from the LIMIT RCT, in relation to detecting hypothesised effects of interest (intervention and pre-pregnancy maternal BMI) as well as effects known to be spurious, and known to be present.

Methods

DNAm data, from 645 cord blood samples analysed using Illumina 450K BeadChip arrays, were normalised using three different methods (with probe filtering undertaken pre- or post- normalisation). Batch effects were handled with a supervised algorithm, an unsupervised algorithm, or adjustment in the analysis model. Analysis was undertaken with and without adjustment for estimated cell type proportions. The effects estimated included intervention and BMI (effects of interest in the original study), infant sex and randomly assigned groups. Data processing and analysis methods were compared in relation to number and identity of differentially methylated probes, rankings of probes by p value and log-fold-change, and distributions of p values and log-fold-change estimates.

Results

There were differences corresponding to each of the processing and analysis choices. Importantly, some combinations of data processing choices resulted in a substantial number of spurious 'significant' findings. We recommend greater emphasis on replication and greater use of sensitivity analyses.

The Role of Lifestyle Interventions in the Prevention and Treatment of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common pregnancy-related endocrinopathies, affecting up to 25% of pregnancies globally. GDM increases the risk of perinatal and delivery complications, and the chance of developing type 2 diabetes mellitus and its complications, including cardiovascular diseases. This elevated risk is then passed on to the next generation, creating a cycle of metabolic dysfunction across generations. For many years, GDM preventive measures have had inconsistent results, but recent systematic reviews and meta-analyses have identified promising new preventative routes. This review aims to summarize the evidence investigating the efficacy of lifestyle treatments for the prevention of GDM and to summarize the effects of two lifestyle interventions, including physical activity and dietary interventions. Based on the present research, future studies should be conducted to investigate whether initiating lifestyle interventions during the preconception period is more beneficial in preventing GDM. In addition, research targeting pregnancy should be designed with a personalized approach. Therefore, studies should customize intervention approaches depending on the presence of modifiable and non-modifiable risk factors at the individual level.

Prenatal interventions and the development of childhood obesity

BACKGROUND

Excess maternal adiposity during pregnancy has lasting effects on child outcomes including increased risk of overweight/obesity, which drives disease development. Prenatal interventions are a potential avenue to curb childhood obesity rates, but little is known on their long-term influence on offspring adiposity.

OBJECTIVE

Review the evidence for lasting effects of prenatal interventions on child adiposity.

METHODS

Three databases were searched for follow-up studies of completed prenatal RCTs that involved a diet, exercise, or combined (diet and exercise) intervention, and assessed offspring adiposity-related outcomes beyond birth.

RESULTS

A total of 18 follow-up studies describing 4277 offspring were included. Anthropometrics were collected in all studies while body composition was measured in 15 of the studies. Diet or exercise interventions did not have a consistent significant effect on child adiposity. Three combined interventions resulted in lower levels of child adiposity at 3, 6, and 12 months.

CONCLUSIONS

No strong association was found between prenatal diet, exercise, or combined interventions and child adiposity. Data are limited due to 63.6% overall retention rate for the follow-up studies and heterogeneity of intervention approach and child adiposity measures. Findings suggest combined interventions initiated early in pregnancy may decrease offspring adiposity in the first year of life.

Lifestyle Interventions to Improve Pregnancy Outcomes: a Systematic Review and Specified Meta-Analyses

To compare the impact of lifestyle interventions for overweight and obese pregnant women a systematic review and meta-analysis was conducted using pre-registration and audit of the interventions as selection criteria. PubMed, Web of Science and CENTRAL were searched for randomized controlled trials examining diet, exercise, combined interventions or associated behavioral therapy. Trials were selected if they reported one of the primary outcomes (gestational diabetes, hypertensive disorders, perinatal mortality, admission to neonatal intensive care unit). Results were established from the total group and separately from pre-registered or clinically audited studies. Out of 1304 titles, 28 randomized controlled trials were included. Among the primary outcomes only hypertensive disorders were significantly reduced by exercise in the total group: odds ratio 0.52 (95% confidence interval 0.28 to 0.96, four trials, 1324 participants). When behavioral therapy supported combined interventions, maternal weight gain, (Standardized Mean Difference -0.16 kilogram; 95% confidence interval -0.28 to -0.04, four trials, 2132 participants) and neonatal birthweight, (Standardized Mean Difference -0.4 gram; 95% confidence interval -0.62 to -0.18, five trials, 1058 participants), were significantly reduced within the total group and both specified meta-analyses. Higher frequencies of physical activity improved the results. Risk of bias, assessed with the Cochrane Tool, was low to moderate. Elements of behavioral therapy might better prevent adverse effects of maternal obesity when combined with lifestyle interventions. Unfortunately, high heterogeneity due to different intervention and population characteristics was a limiting factor. Future studies should also focus on increased intensities of physical activity.

Weight Changes, Nutritional Intake, Food Contaminants, and Supplements in Women of Childbearing Age, including Pregnant Women: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Adequate maternal nutrition is crucial for a healthy pregnancy and optimal fetal growth. Many women in France of childbearing age start their pregnancy in an unfavorable nutritional status. Recent studies highlight the value of paying attention to weight issues from the preconceptional period. It is important to call attention to the need for folate supplementation and to promote a varied and balanced diet throughout pregnancy to cover essential nutritional needs.

Parental obesity-induced changes in developmental programming

Many studies support the link between parental obesity and the predisposition to develop adult-onset metabolic syndromes that include obesity, high blood pressure, dyslipidemia, insulin resistance, and diabetes in the offspring. As the prevalence of obesity increases in persons of childbearing age, so does metabolic syndrome in their descendants. Understanding how parental obesity alters metabolic programs in the progeny, predisposing them to adult-onset metabolic syndrome, is key to breaking this cycle. This review explores the basis for altered metabolism of offspring exposed to overnutrition by focusing on critical developmental processes influenced by parental obesity. We draw from human and animal model studies, highlighting the adaptations in metabolism that occur during normal pregnancy that become maladaptive with obesity. We describe essential phases of development impacted by parental obesity that contribute to long-term alterations in metabolism in the offspring. These encompass gamete formation, placentation, adipogenesis, pancreas development, and development of brain appetite control circuits. Parental obesity alters the developmental programming of these organs in part by inducing epigenetic changes with long-term consequences on metabolism. While exposure to parental obesity during any of these phases is sufficient to alter long-term metabolism, offspring often experience multiple exposures throughout their development. These insults accumulate to increase further the susceptibility of the offspring to the obesogenic environments of modern society.

Effectiveness of a nurse practitioner-led cardiovascular prevention clinic at reduction of metabolic syndrome following maternal complications of pregnancy: a preliminary analysis

AIM

Maternal complications of pregnancy, including hypertensive disorders of pregnancy, gestational diabetes mellitus, intrauterine growth restriction, preterm labour, and placental abruption, are associated with increased risk of future cardiometabolic disease. Lifestyle interventions that focus on preventative strategies for this young, high-risk population of women may assist in cardiometabolic disease risk reduction. The aim of this preliminary registry analysis was to observe the change in maternal metabolic syndrome status after receiving a nurse practitioner-led lifestyle intervention delivered soon after a complicated pregnancy.

METHOD

This preliminary analysis included 64 eligible women who had attended both baseline (approximately 6 months postpartum) and review (approximately eighteen months postpartum) appointments at the postpartum lifestyle clinic after an index pregnancy complicated by at least one maternal complication of pregnancy. Metabolic syndrome status at both appointments was assessed.

RESULTS

At the baseline appointment, 22 (34.4%) women met the criteria for metabolic syndrome. This number reduced at the review appointment to 19 (29.7%). This difference was not statistically significant. There were some modest improvements in the individual cardiometabolic risk factors, as well as marked improvements in the women who had recovered from metabolic syndrome over twelve months.

CONCLUSION

There was a high percentage of metabolic syndrome present early in the postpartum period. The results of this preliminary analysis highlight the importance of continuing preventative care and ongoing research for this group of high-risk women.

Implementation of Antenatal Lifestyle Interventions Into Routine Care: Secondary Analysis of a Systematic Review

IMPORTANCE

Lifestyle interventions in pregnancy optimize gestational weight gain and improve pregnancy outcomes, with implementation recommended by the US Preventive Services Task Force. Yet, implementation research taking these efficacy trials into pragmatic translation remains limited.

OBJECTIVE

To evaluate success factors for implementing pregnancy lifestyle interventions into antenatal care settings in a meta-analysis, using the penetration, implementation, participation, and effectiveness (PIPE) impact metric.

DATA SOURCES

Data from a previous systematic review that searched across 9 databases, including 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, were obtained, in 2 stages, up to May 6, 2020.

STUDY SELECTION

Randomized clinical trials reporting gestational weight gain in singleton pregnancies.

DATA EXTRACTION AND SYNTHESIS

The association of penetration, implementation, and participation with effectiveness of antenatal lifestyle interventions in optimizing gestational weight gain was estimated using random-effects meta-analyses. The Cochrane risk of bias tool, version 1.0, was used to assess risk of bias.

MAIN OUTCOMES AND MEASURES

Penetration (reach), implementation (fidelity), participation, and effectiveness of randomized clinical trials of lifestyle interventions in pregnancy.

RESULTS

Ninety-nine studies with 34 546 participants were included. Only 14 studies reported penetration of target populations. Overall, 38 studies (38.4%) had moderate fidelity, 25 (25.2%) had high fidelity, and 36 (36.4%) had unclear fidelity. Participation was reported in 84 studies (84.8%). Lifestyle interventions were associated with reducing gestational weight gain by 1.15 kg (95% CI, -1.40 to -0.91 kg).

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that, despite the large body of evidence on efficacy of lifestyle interventions during pregnancy in optimizing gestational weight gain, little guidance is available to inform implementation of this evidence into practice. There is a need to better elucidate implementation outcomes in trial design alongside pragmatic implementation research to improve the health of women who are pregnant and the next generation.

Determinants of rapid infant weight gain: A pooled analysis of seven cohorts

OBJECTIVE

Rapid weight gain (RWG) in infancy is strongly associated with subsequent obesity risk, but little is known about the factors driving RWG. This study explored the child and maternal factors associated with infant RWG.

METHODS

Data from seven Australian and New Zealand cohorts were used (n = 4542). Infant RWG was defined as a change in weight z-score ≥0.67 from birth to age 1 year. Univariable and multivariable logistic regression assessed the association between child and maternal factors and infant RWG in each cohort. Meta-analysis was conducted to obtain pooled effect sizes.

RESULTS

Multivariable analyses revealed boys were more likely to experience RWG (OR 1.42 95% CI 1.22, 1.66) than girls. Higher birth weight in kg (OR 0.09, 95% CI 0.04, 0.20) and gestational age in weeks (OR 0.69, 95% CI 0.48, 0.98) were associated with lower RWG risk. Children who were breastfed for ≥6 months showed lower RWG risk (OR 0.45, 95% CI 0.38, 0.53). Children of native-born versus overseas-born women appeared to have higher RWG risk (OR 1.37, 95% CI 0.99, 1.90). Maternal smoking during pregnancy increased RWG risk (OR 1.60, 95% CI 1.28, 2.01), whereas children who started solids ≥6 months (OR 0.77, 95% CI 0.63, 0.93) and children with siblings (OR 0.68, 95% CI 0.57, 0.81) showed lower RWG risk in univariable analysis, but these associations were attenuated in multivariable analysis. No association was found for maternal age, education, marital status and pre-pregnancy BMI.

CONCLUSION

Maternal country of birth, smoking status, child sex, birth weight, gestational age, infant feeding and parity were potential determinants of infant RWG.

Immediate weight loss before ovarian stimulation with intrauterine insemination is associated with a lower risk of preeclampsia in women with obesity and unexplained infertility

Objective

To determine whether successful weight loss before ovarian stimulation with intrauterine insemination (OS-IUI) affects the risk of future pregnancy complications among women with obesity and unexplained infertility after fertility treatment.

Design

Secondary analysis of the randomized controlled clinical trial Improving Reproductive Fitness Through Pretreatment With Lifestyle Modification in Obese Women With Unexplained Infertility (FIT-PLESE).

Setting

Multiple academic health centers in the United States.

Patient(s)

Three hundred seventy-nine women with obesity and unexplained infertility who underwent standard infertility treatment after a lifestyle intervention.

Intervention(s)

The FIT-PLESE trial evaluated whether prepregnancy lifestyle interventions (diet with weight loss medication and exercise vs. exercise alone) before OS-IUI improved the live birth rate among women with obesity and unexplained infertility. Although the primary outcome of FIT-PLESE was live birth rate, we compared the demographics and subsequent pregnancy complications of women who successfully lost some weight with those of women who did not lose any during the interventions.

Main Outcome Measure(s)

Obstetric complications by groups were compared using χ² and Fisher’s exact tests, and continuous variables were compared using Student’s t-tests. Logistic regression was used to assess the odds of preeclampsia after adjustment for the randomized treatment arm in FIT-PLESE.

Result(s)

There was a nonsignificant trend toward a lower risk of intrauterine growth restriction (4% vs. 16%, P = .124) and preterm delivery (6% vs. 15%, P = .343) among patients who lost at least some weight. The risk of preeclampsia was significantly lower (6% vs.35%, P = .002) in the weight loss group (odds ratio, 0.09; 95% confidence interval, 0.016–0.505; P = .006) after adjustment for treatment assignment.

Conclusion(s)

Among women with obesity and unexplained infertility who had live births after fertility treatment, prepregnancy weight loss due to lifestyle interventions before OS-IUI was associated with a lower risk of preeclampsia.

Programming by maternal obesity: a pathway to poor cardiometabolic health in the offspring

There is an ever increasing prevalence of maternal obesity worldwide such that in many populations over half of women enter pregnancy either overweight or obese. This review aims to summarise the impact of maternal obesity on offspring cardiometabolic outcomes. Maternal obesity is associated with increased risk of adverse maternal and pregnancy outcomes. However, beyond this exposure to maternal obesity during development also increases the risk of her offspring developing long-term adverse cardiometabolic outcomes throughout their adult life. Both human studies and those in experimental animal models have shown that maternal obesity can programme increased risk of offspring developing obesity and adipose tissue dysfunction; type 2 diabetes with peripheral insulin resistance and β-cell dysfunction; CVD with impaired cardiac structure and function and hypertension via impaired vascular and kidney function. As female offspring themselves are therefore likely to enter pregnancy with poor cardiometabolic health this can lead to an inter-generational cycle perpetuating the transmission of poor cardiometabolic health across generations. Maternal exercise interventions have the potential to mitigate some of the adverse effects of maternal obesity on offspring health, although further studies into long-term outcomes and how these translate to a clinical context are still required.

Limiting Postpartum Weight Retention in Culturally and Linguistically Diverse Women: Secondary Analysis of the HeLP-her Randomized Controlled Trial

Postpartum weight retention (PPWR) contributes to maternal obesity development and is more pronounced in culturally and linguistically diverse (CALD) women. Our antenatal healthy lifestyle intervention (HeLP-her) demonstrated efficacy in reducing PPWR in non-Australian-born CALD women compared with Australian-born women. In this secondary analysis, we aimed to examine differences in the intervention effect on behavioral and psychosocial outcomes between Australian-born and non-Australian-born women and explore factors associated with the differential intervention effect on PPWR. Pregnant women at risk of gestational diabetes (Australian-born n = 86, non-Australian-born n = 142) were randomized to intervention (four lifestyle sessions) or control (standard antenatal care). PPWR was defined as the difference in measured weight between 6 weeks postpartum and baseline (12–15 weeks gestation). Behavioral (self-weighing, physical activity (pedometer), diet (fat-related dietary habits questionnaire), self-perceived behavior changes), and psychosocial (weight control confidence, exercise self-efficacy, eating self-efficacy) outcomes were examined by country of birth. Multivariable linear regression analysis was conducted to assess factors associated with PPWR. The intervention significantly increased self-weighing, eating self-efficacy, and self-perceived changes to diet and physical activity at 6 weeks postpartum in non-Australian-born women, compared with no significant changes observed among Australian-born women. Intervention allocation and decreased intake of snack foods were predictors of lower PPWR in non-Australian-born women. Results indicate that the HeLP-her intervention improved dietary behaviors, contributing to the reduction of PPWR in CALD women. Future translations could prioritize targeting diet while developing more effective strategies to increase exercise engagement during pregnancy in this population.

Maternal overweight and obesity during pregnancy: strategies to improve outcomes for women, babies, and children

INTRODUCTION

Women with overweight and obesity, and their children, are at increased risk of adverse pregnancy, birth, and longer term health outcomes, believed to be compounded by excessive gestational weight gain (GWG). Research to date has focused on interventions to reduce excessive GWG through changes to maternal diet and/or lifestyle.

AREAS COVERED

Current clinical recommendations for GWG vary according to a woman's early pregnancy body mass index, based on assumptions that associations between GWG and adverse pregnancy outcomes are causal in nature, and modifiable. While there are small differences in GWG following pregnancy interventions, there is little evidence for clinically relevant effects on pregnancy, birth, and longer term childhood outcomes. This review considers interventional studies targeting women with overweight or obesity to reduce GWG in an effort to improve maternal and infant health, and the current evidence for interventions prior to conception.

EXPERT OPINION

GWG is not modifiable via diet and lifestyle change, and continued efforts to find the 'right' intervention for women with overweight and obesity during pregnancy are unjustified. Researchers should focus on gathering evidence for interventions prior to pregnancy to optimize maternal health and weight to improve pregnancy, birth, and longer term health outcomes associated with obesity.

Low prenatal resting energy expenditure and high energy intake predict high gestational weight gain in pregnant women with overweight/obesity

INTRODUCTION

Recent evidence suggests that low resting energy expenditure (REE) is associated with gestational weight gain (GWG). However, little research has examined whether REE explains GWG beyond the contributions of energy intake (EI) and physical activity (PA). This study examined the extent to which EI, PA, and REE were associated with and explained second trimester GWG in pregnant women with overweight/obesity.

METHODS

Pregnant women with overweight/obesity (N = 26) participating in the Healthy Mom Zone study, a theoretically-based behavioral intervention that adapted the intervention dosage over time to regulate GWG completed weekly point estimates of EI (back-calculation), PA (wrist-worn activity monitor), and REE (mobile metabolism device) from 14- to 28-weeks gestation. Second trimester GWG was calculated as the weekly point estimate of weight from a Wi-Fi weight scale at gestational week 28 minus the weekly point estimate of weight at gestational week 14.

RESULTS

Partial correlations revealed second trimester EI and PA were not significantly associated with second trimester GWG, but low second trimester REE was significantly associated with high second trimester GWG. Hierarchical regression analyses showed the model of fat-free mass, EI, PA, and REE explained 56% of the variance in second trimester GWG. Low REE was the strongest determinant followed by high EI; fat-free mass and PA were not significant predictors.

CONCLUSIONS

While EI and PA remain important determinants of GWG, future researchers should explore the role of REE to inform individualized EI and PA goals to better regulate GWG.

Practical guide for the management of hypertensive disorders during pregnancy

Hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and eclampsia, are a worldwide health problem. Hypertensive disorders of pregnancy affect more than 10% of pregnancies and are associated with increased mortality and morbidity for both mother and fetus. Although patients' outcomes and family's experience will always be the primary concern regarding hypertensive complications during pregnancy, the economic aspect of this disease is also worth noting. Compared with normotensive pregnancies, those related with hypertension resulted in an excess increase in hospitalization and healthcare cost. Hence, the focus of this review is to analyze hypertensive disorders of pregnancy and to present practical tips with clear instructions for the clinical management of hypertensive disorders of pregnancy. This overview offers a detailed approach from the diagnosis to treatment and follow-up of a pregnant women with hypertension, evidence based, to support these instructions.

Effect of an antenatal diet and lifestyle intervention and maternal BMI on cord blood DNA methylation in infants of overweight and obese women: The LIMIT Randomised Controlled Trial

Background

To investigate the effect of an antenatal diet and lifestyle intervention, and maternal pre-pregnancy overweight or obesity, on infant cord blood DNA methylation.

Methods

We measured DNA methylation in 645 cord blood samples from participants in the LIMIT study (an antenatal diet and lifestyle intervention for women with early pregnancy BMI ≥25.0 kg/m2) using the Illumina 450K BeadChip array, and tested for any differential methylation related to the intervention, and to maternal early pregnancy BMI. We also analysed differential methylation in relation to selected candidate genes.

Results

No CpG sites were significantly differentially methylated in relation to either the diet and lifestyle intervention, or with maternal early pregnancy BMI. There was no significant differential methylation in any of the selected genes related to the intervention, or to maternal BMI.

Conclusion

We found no evidence of an effect of either antenatal diet and lifestyle, or of maternal early pregnancy BMI, on cord blood DNA methylation.

Clinical trials registration

ACTRN12607000161426

Prevention of Gestational Diabetes Mellitus and Gestational Weight Gain Restriction in Overweight/Obese Pregnant Women: A Systematic Review and Network Meta-Analysis

Background: Overweight/obesity is associated with pregnancy-related disorders, such as gestational diabetes mellitus (GDM) and excessive gestational weight gain (GWG). Although multiple interventions have been proposed to prevent GDM and restrict GWG, our knowledge of their comparative efficacy is limited. Objective: To evaluate the effectiveness and identify the optimal intervention strategy to prevent GDM and restrict GWG among overweight/obese pregnant women. Methods: Randomized controlled trials that recruited overweight/obese pregnant women at <20 gestational week were obtained. Predictive and confidence interval plot and surface under the cumulative ranking (SUCRA) were performed using Stata statistical software to determine and compare the efficacy of interventions (diet, physical activity (PA), diet + PA intervention and medication). Results: 23 studies with a total of 8877 participants were eligible for analysis. Our results indicated that although neither PA, diet + PA, diet nor medication intervention could significantly protect overweight/obese women from the development of GDM, there was a trend that PA and diet + PA intervention were preventive factors of GDM. Of these, PA intervention (SUCRA, 82.8%) ranked as the superior strategy, and diet intervention (SUCRA, 19.7%) was the least efficacious regimen. Furthermore, interventions of diet, PA and diet + PA were significantly beneficial for GWG restriction, whereas medication intervention could not restrict GWG. In detail, diet intervention (SUCRA, 19.7%) ranked as the optimal regimen, whilst PA intervention (SUCRA, 62.3%) ranked as the least efficacious regimen. Conclusion: Although none of the interventions could offer remarkable benefit for GDM prevention, interventions of diet, PA and diet + PA were significant factors to restrict GWG. In aggregate, diet + PA intervention seemed the superior choice for the prevention of both GDM and excessive GWG. Registration: PROSPERO CRD42022313542.

Diet Modification before or during Pregnancy on Maternal and Foetal Outcomes in Rodent Models of Maternal Obesity

The obesity epidemic has serious implications for women of reproductive age; its rising incidence is associated not just with health implications for the mother but also has transgenerational ramifications for the offspring. Increased incidence of diabetes, cardiovascular disease, obesity, and kidney disease are seen in both the mothers and the offspring. Animal models, such as rodent studies, are fundamental to studying maternal obesity and its impact on maternal and offspring health, as human studies lack rigorous controlled experimental design. Furthermore, the short and prolific reproductive potential of rodents enables examination across multiple generations and facilitates the exploration of interventional strategies to mitigate the impact of maternal obesity, both before and during pregnancy. Given that obesity is a major public health concern, it is important to obtain a greater understanding of its pathophysiology and interaction with reproductive health, placental physiology, and foetal development. This narrative review focuses on the known effects of maternal obesity on the mother and the offspring, and the benefits of interventional strategies, including dietary intervention, before or during pregnancy on maternal and foetal outcomes. It further examines the contribution of rodent models of maternal obesity to elucidating pathophysiological pathways of disease development, as well as methods to reduce the impact of obesity on the mothers and the developing foetus. The translation of these findings into the human experience will also be discussed.

Effects of pre-pregnancy BMI and gestational weight gain on adverse pregnancy outcomes and complications of GDM

To investigate the effects of pre-pregnancy BMI and gestational weight gain on adverse pregnancy outcomes and complications of gestational diabetes mellitus. 3966 pregnant women were enrolled in this study. Multivariate logistic regression analysis was conducted to estimate the relative risk between pre-pregnancy BMI, gestational weight gain, and adverse pregnancy outcome. Pre-pregnancy BMI was found to be a risk factor for preeclampsia (OR = 1.159), gestational diabetes mellitus (OR = 1.191), gestational hypertension (OR = 1.221), and macrosomia (OR = 1.165). Gestational weight gain was a risk factor for preeclampsia (OR = 1.783), placental abruption (OR = 2.209), and macrosomia (OR = 1.506). Total weight gain during pregnancy cannot be used as a predictor of GDM. Pre-pregnancy BMI is a risk factor for gestational diabetes mellitus complicated with preeclampsia, preterm delivery, gestational hypertension, and macrosomia. Impact statementWhat is already known on this subject? Obesity during pregnancy includes pre-pregnancy obesity and excessive weight gain during pregnancy. Obese pregnant women have a higher risk of pregnancy complications.What do the results of this study add? We focus on the effects of pre-pregnancy BMI on pregnancy outcomes, classified by Asian criteria. Our findings suggest for the first time that excessive weight gain during pregnancy is a risk factor for placental abruption and we specifically point out that total weight gain during pregnancy cannot be used as a predictor of GDM.What are the implications of these findings for clinical practice and/or further research? This study is helpful to monitor the risk of adverse pregnancy outcomes in the Asian population and suggest the risk of pregnancy complications, such as gestational diabetes mellitus and placental abruption.

Efficacy of behavioral interventions in managing gestational weight gain (GWG): A component network meta-analysis

OBJECTIVE

To identify the most effective behavioral components within lifestyle interventions to optimize gestational weight gain (GWG) to inform guidelines, policy and translation into healthcare.

METHODS

Behavioral components were identified from study level data of randomized antenatal lifestyle interventions using a behavioral taxonomy framework and analyzed using component network meta-analysis (NMA). The NMA ranked behavioral combinations hierarchically by efficacy of optimizing GWG. Direct and estimated indirect comparisons between study arms (i.e., control and intervention) and between different component combinations were estimated to evaluate component combinations associated with greater efficacy.

RESULTS

Overall, 32 studies with 11,066 participants were included. Each intervention contained between 3 and 7 behavioral components with 26 different behavioral combinations identified. The majority (n = 24) of combinations were associated with optimizing GWG, with standard mean differences (SMD) ranging from -1.01 kg (95% CI -1.64 to -0.37) and -0.07 kg (-0.38 to 0.24), compared with controls. The behavioral cluster identified as most effective, included components of goals, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge (SMD -1.01 kg [95% CI -1.64 to -0.37]).

CONCLUSION

Findings support the application of goal setting, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge as essential, core components within lifestyle interventions to optimize gestational weight gain.

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

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

Global Research Trends in Gestational Diabetes Mellitus from 2000 to 2020: A Bibliometric Study

AIMS

This study analyzed major trends and topics in the field of gestational diabetes mellitus research between 2000 and 2020.

METHODS

Studies that investigated gestational diabetes mellitus published between 2000 and 2020 were retrieved from the Web of Science Core Collection database. Data from the identified studies were analyzed using CiteSpace software.

RESULTS

A total of 22,713 publications were retrieved, among which 21,722 publications were included in this scientometric analysis. Clustering analysis revealed 13 themes across all fields. Physical activity is an emerging trend. Co-word analysis showed that subject high-frequency keywords were: risk factor, obesity, insulin resistance, prevalence, and association. Centrality indices identified the most influential keywords to be: body mass index, risk factors, gestational weight gain, and obesity. Burst keywords revealed that there were six research frontier subtopics: i) prediction of adverse neonatal outcomes in gestational diabetes mellitus; ii) postpartum period research - blood glucose levels and insulin resistance; iii) meta-analysis - understanding the best evidence in pregnancy gestational diabetes mellitus; iv) gene expression profiles and DNA methylation in gestational diabetes mellitus; v) biomarkers for predicting higher birth and children weights; and vi) discussion on diagnostic criteria for gestational diabetes mellitus classification.

CONCLUSION

The number of studies on gestational diabetes mellitus is increasing. For two decades, the United States has been the global leader in the number of published studies. Studies on gestational diabetes mellitus are mainly from developed countries, with a few of them being from developing countries. An emerging field of research aims at elucidating the association between physical activity and gestational diabetes mellitus.

A high-protein low-glycemic index diet attenuates gestational weight gain in pregnant women with obesity: the "An optimized programming of healthy children" (APPROACH) randomized controlled trial

BACKGROUND

Prepregnancy overweight and excessive gestational weight gain (GWG) increase the risk of complications and offspring obesity.

OBJECTIVES

We aimed to investigate the effect of a high-protein low-glycemic index (HPLGI) diet on GWG, birth weight, and risk of gestational complications in pregnant women with obesity.

METHODS

A total of 279 women with prepregnancy overweight or obesity (BMI: 28-45 kg/m2), between 18 and 45 y old, and in their late first trimester with singleton pregnancies, were randomly assigned to 1 of 2 ad libitum diets: a high-protein low-glycemic index diet (HPLGI: 25%-28% of energy from protein and glycemic index ≤ 55) and a moderate-protein moderate-glycemic index diet (MPMGI: 15%-18% of energy from protein and glycemic index ∼60). Diets were consumed from gestational week 15 and throughout pregnancy. Participants received dietary guidance by a clinical dietician 9 times to facilitate adherence.

RESULTS

Out of 141 and 138 women randomly assigned to the HPLGI and MPMGI diets, 105 and 104 completed the intervention, respectively (75%). In the available case analyses, GWG was 6.8 ± 1.3 kg among women assigned the HPLGI diet and this was significantly lower, by -1.7 kg (95% CI: -2.8, -0.5 kg; P = 0.004), than the GWG of 8.5 ± 1.3 kg among women assigned the MPMGI diet. There were no significant differences between diets on major neonatal outcomes (birth weight and other anthropometric measures). The incidence of composite pregnancy complications was lower for the HPLGI than for the MPMGI diet (35.4% compared with 53.7%, respectively; P = 0.009), including cesarean delivery (15.4% compared with 28.8%, respectively; P = 0.03). There were no reported maternal, fetal, or neonatal deaths. Incidence of miscarriages (1%-2%) did not differ between groups.

CONCLUSIONS

A moderate increase in dietary protein in conjunction with a reduction in glycemic index during the last 2 trimesters of pregnancy reduced GWG and limited complications and cesarean deliveries among women with overweight or obesity.

Application of Mobile Technology for Disease and Treatment Monitoring of Gestational Diabetes Mellitus Among Pregnant Women: A Systematic Review

BACKGROUND

Gestational diabetes mellitus (GDM) is an increasing health issue among pregnant women worldwide. Treatment of hyperglycemia during pregnancy improves outcomes for both mothers and infants. Effectively performing and reviewing self-monitoring of blood glucose is time-consuming for patients and care providers. In the modern era, most people having access to smartphones create opportunities for use of phone-based technologies to improve patient care in chronic diseases. This review aims to investigate the awareness and use of the smartphone application (app) with respect to management of GDM among pregnant women.

MATERIALS AND METHODS

Various relevant studies (n = 522) from 3 databases named Pub Med, Cochrane Library, and Google Scholar were included. For this, the study involved designing of a 5-stage review framework, which included research question identification, identification of articles, article selection, data collection, and result reporting.

RESULTS

Initial search criteria used a combination of keywords, by which we found out 522 literatures from 3 databases. After screening the titles and abstracts, 249 articles were excluded due to duplicate literatures and 252 articles were excluded due to the following reasons: not relevant (n = 172), editorial (n = 43), not in English (n = 7), and abstract only (n = 30). Furthermore, 10 articles were excluded because apps such as MobiGuide, pregnant + app, and GDm health were not mentioned in these articles. A total of 11 articles were included for the final analysis.

CONCLUSION

The mobile apps described in the present study (pregnant +, MobiGuide, and GDm health) provided personalized health care services, patient care improvement, and enhanced patient's compliance toward blood glucose monitoring and treatment.

Independent effect of gestational weight gain and prepregnancy obesity on pregnancy outcomes among Saudi women: A sub-cohort analysis from Riyadh mother and baby cohort study (RAHMA)

Background

Gestational weight gain (GWG) and prepregnancy obesity are garnering more attention as determining factors of pregnancy outcomes when it comes to the wellbeing of both the mother and her baby. This study was conducted to describe the pattern of GWG among participants of Riyadh Mother and Baby Multicenter Cohort Study (RAHMA) and to investigate the detrimental effects of excessive GWG and prepregnancy obesity on pregnancy outcomes.

Methods

RAHMA is a multicentre cohort study conducted in three hospitals in Riyadh, Saudi Arabia. Participants were categorized according to the Institute of Medicine into inadequate, adequate, and excessive GWG, and stratified by body mass index (BMI) into under/normal weight, overweight, and obese. To examine the independent effect of maternal prepregnancy obesity and GWG, a multivariate regression model was used and adjusted odds ratio (AOR) and 95% Confidence Interval (CI) for each outcome were calculated.

Results

A total of 7029 participants were included in this study; 31.8% had adequate GWG, 25.9% had excessive GWG and 42.3% had inadequate GWG, while 29.7% had normal BMI, 33.3% were overweight, 34.8% were obese, and 2.2% were underweight. Excessive GWG was independently associated with increased risk of hypertensive events, (AOR = 1.77, 95% CI 1.20–2.63). Obesity was associated with higher risk of gestational diabetes (AOR 2.11, 95% CI 1.76–2.53), hypertensive events (AOR 2.06, 95% CI 1.48–3.01), and delivery by emergency caesarean section (AOR = 1.63, 95% CI 1.35–1.97). Infants of obese women had increased odds of macrosomia (AOR 3.11, 95% CI 1.94–4.99) and lower odds of low birth weight (AOR = 0.68, 95% CI 0.53–0.88).

Conclusion

In comparison to excessive GWG, which increases the risk of hypertensive events during pregnancy, prepregnancy obesity is associated with more adverse outcomes including GDM, hypertensive events in pregnancy and emergency CS.

Gestational Diabetes and Overweight/Obesity: Analysis of Nulliparous Women in the U.S., 2011-2019

INTRODUCTION

The rates of gestational diabetes mellitus are increasing in parallel with the rates of overweight and obesity. This analysis examines nationwide trends in the population-attributable fraction for gestational diabetes mellitus associated with prepregnancy overweight and obesity.

METHODS

A serial, cross-sectional study was performed using U.S. population-based birth data files maintained by the National Center for Health Statistics between 2011 and 2019. Live singleton births to nulliparous women aged 15-44 years were included, and all analyses were stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian). Prevalences of prepregnancy overweight (25.0-29.9 kg/m2 and 23.0-27.4 kg/m2) and obesity (≥30.0 kg/m2 and ≥27.5 kg/m2) based on standard and Asian-specific BMI categories, respectively, were quantified. Logistic regression estimated the adjusted associations between prepregnancy overweight and obesity and gestational diabetes mellitus, with normal weight (18.0-24.9 kg/m2and 18.0-22.9 kg/m2) as the ref. Annual population-attributable fractions for gestational diabetes mellitus associated with prepregnancy overweight and obesity were calculated, which account for both the prevalence of the risk factor and the associated risk of gestational diabetes mellitus.

RESULTS

Among 11,950,881 included women, the mean maternal age was 26.3 years. From 2011 to 2019, the population-attributable fractions for gestational diabetes mellitus associated with overweight were stable (Hispanic: 12.0%-11.3%, non-Hispanic Asian: 12.1%-11.6%, p≥0.20) or decreased (non-Hispanic White: 10.8%-9.4%, non-Hispanic Black: 12.3%-9.2%, p<0.002); the population-attributable fractions for gestational diabetes mellitus associated with obesity were stable (non-Hispanic Black: 36.3%-37.9%, p=0.11) or increased (non-Hispanic White: 30.9%-33.3%, Hispanic: 27.2%-33.3%, non-Hispanic Asian 12.2%-15.4%, p<0.001).

CONCLUSIONS

The population-attributable fractions for gestational diabetes mellitus associated with obesity largely increased in the past decade, underscoring the importance of optimizing weight before pregnancy.

Preconceptional maternal weight loss and hypertensive disorders in pregnancy: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), Preeclampsia (PE), Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) and chronic hypertension, are leading causes of maternal and perinatal morbidity and mortality. Although the pathophysiology of HDP is complex, preconceptional weight reduction in obese women might reduce these complications. We conducted a systematic review and meta-analysis to investigate the effectiveness of preconceptional weight loss by lifestyle intervention or bariatric surgery in overweight and obese women and the reduction of the risk of HDP.

METHODS AND RESULTS

Databases are searched until September 2019 resulting in 2547 articles: 110 full-text analysis and 29 detailed analysis. Reduced risks were shown for HDP in seven articles (n = 4381) of weight loss after lifestyle intervention or bariatric surgery (OR range 0.10-0.64), for PIH in four articles (n = 46,976) (OR range 0.14-0.79), and for PE in seven articles (n = 169,734) (OR range 0.14-0.84). The stratified analysis of weight loss after lifestyle intervention and bariatric surgery shows comparable results. The meta-analysis of 20 studies of the effectiveness of lifestyle intervention and bariatric surgery revealed reduced risks of HDP (OR 0.45 (95% CI 0.32-0.63)), PIH (OR 0.61 (95%CI 0.44-0.85)) and PE (OR 0.67 (95%CI 0.51-0.88)).

CONCLUSIONS

Preconceptional weight loss after lifestyle intervention or bariatric surgery is effective in reducing risks of HDP, PIH and PE, and emphasizes the need to optimize weight in overweight and obese women with a child wish. More research is recommended to investigate short-term and long-term beneficial and harmful side-effects of these interventions on maternal and offspring health.

Nutrition as Prevention Factor of Gestational Diabetes Mellitus: A Narrative Review

Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder with onset or first recognition during pregnancy. GDM is associated with several adverse maternal and neonatal outcomes. Management to reduce the incidence of GDM could decrease the incidence of these complications. Modification of nutrition in the prevention of GDM is postulated. The vital issue in GDM prevention is the implementation of proper dietary patterns, appropriate physical activity, and a combination of diet and lifestyle modifications. However, intervention studies examining the effects of diet and lifestyle on GDM prevention are contradictory. The aim of this study was to review the scientific evidence on nutritional prevention strategies, including diet and supplementation of some substances such as probiotics, micro/macroelements, fiber, myoinositol, and vitamins that may be effective in reducing the risk of GDM. The presented article is a narrative review. This article indicates that certain nutritional factors may have some benefit in preventing GDM. However, further studies in a variety of populations and large groups of patients are needed. At present, no definitive conclusions can be drawn as to the best intervention in the prevention of GDM.