Dietary interventions in
Obese Pregnancy:
An Australian study and
systematic review of the literature
Professor Julie Quinlivan
Prevalence
In Australia and
New Zealand,
35% of women
presenting for
antenatal care are
overweight or
obese
Ball K et al, Pub Hlth Nutr 2003;
Lederman SA. Obstet Gynecol 1993;
Gunderson & Abrams Epidemiol Rev 2000.
Prevalence
So we have more women than ever
PRESENTING for antenatal care who are
overweight or obese
This is then compounded by women PUTTING
ON more weight in pregnancy than required.
Ball K et al, Pub Hlth Nutr 2003;
Lederman SA. Obstet Gynecol 1993; Gunderson & Abrams Epidemiol Rev 2000.
2. Increasing weight gain in
pregnancy
Period
Mean weight
gain in
pregnancy
1960-1970
8.5-10kg
1980-1990
9-11kg
1990-2000
10-14kg
2000-2010
13-15kg
The excess weight
gain in pregnancy is
FAT women must lose
afterwards.
NHMRC (Australia) Clinical Practice Guidelines for the management of
overweight and obesity in adults, Commonwealth of Australia, Canberra,
2003.; Lederman SA. Obstet Gynecol 1993; 82: 148-55; Hytten and
Chamberlerein , Clinical psychology in Obstetrics. Blackwell Scientific
Publications: Oxford, 1980; Linne Y. Obesity reviews 2004; Chesley and
Weight changes and water balance in normal and toxic pregnancy. Am J
Obstet Gynecol 1944; 48: 565-593. Bongain , Euro J Obstet Gynaecol
Repro Biol 1998.
NHMRC (Aust) reports that
young adult women are at
particular risk of weight gain.
Childbirth is a particular risk.
Up to 20% of women
gain >5kg by 6
months postpartum.
Ball K et al, Pub Hlth Nutr 2003;
Lederman SA. Obstet Gynecol 1993; Gunderson & Abrams Epidemiol Rev
2000.
Ref: 2B blog
spot.com
Implications of obesity
Increased pre-pregnancy weight and weight
gain during pregnancy ADVERSELY increases:
* Gestational diabetes;
* Macrosomia;
* Preterm;
* Postdates;
* Operative delivery;
* Hypertension;
* Infections;
* Clotting disorders.
Example: GDM
What is the impact of maternal BMI on GDM?
Rate of
GDM
25-30
31-40
40+
2-5%
7-12%
17-25%
The obesity epidemic and an increase
in pregnancy weight gain have
increased gestational diabetes.....
.....and then, along comes evidence
that we have been under diagnosing
gestational diabetes to the detriment
of women and their babies.
HAPO
Hyperglycaemia and Adverse Pregnancy
Outcomes study.
It found that there was a CONTINUOUS
relationship between blood glucose and adverse
neonatal and maternal outcomes.
The trial suggested that new guidelines were
required to diagnose GDM.
Cur Opinion Obstet Gynecol 2011; 23(2): 72-5.
The Randomised trials
Two large RCT implementing treatment at old
diagnostic criteria for GDM versus the new
HAPO criteria for GDM
Both RCT found SIGNIFICANT
IMPROVEMENTS in MATERNAL and
NEONATAL outcomes with the treatment of
GDM under the new HAPO guidelines.
Cur Opinion Obstet Gynecol 2011; 23(2): 72-5.
Significant improvements
Birth weight >90th centile
Cord blood C-peptide >90th centile
Caesarean section
Neonatal hypoglycaemia
Pre eclampsia
Preterm birth
Shoulder dystocia
Birth injury
NICU admission
Hyperbilirubinaemia
Annals New York Acad Science 2010; 1205:88-93
Post HAPO
International association of diabetes and pregnancy study groups (IADPSG)
recommendation:
All pregnant women should be offered a 75g
oral GTT between 24-28 weeks gestation.
An ABNORMAL result is any one of the following:
Fasting 5.1 g/dL (92mg/dL)
1 hr 10.0 g/dL (180mg/dL)
2 hr 8.5 g/dL (153mg/dL)
New guidelines and workload
All GTT results from SW and N/Sydney analysed
by old and HAPO criteria.
They found an INCREASE in workload
29-32%
ANZJOG 2010; 50(5): 439-43.
Options
So we need interventions in pregnancy
directed towards obese women that aim
to restrict weight gain in pregnancy to
IOL recommendations and try to reverse
the increase in GDM.
Target weight gains
New Institute of Medicine 2009 guidelines for weight gain in
pregnancy
Overweight women BMI 25 to 29.9
6.8 to 11.3kg
Obese women BMI >30
4.9 to 9kg
Options
* Exercise X
* Psychological X
* Diet ????
Aim
Does a 4-step multidisciplinary approach
to the management of obese pregnant
women reduce weight gain and gestational
diabetes in obese pregnant women?
Quinlivan JA et al, ANZJOG 2011
.
Triangle of intervention
HIGH
LOW
The 4 steps
1. Continuity of care;
2. Measure Weight gain at each visit;
3. Repeated short interventions by a food
technologist;
4. An initial assessment by a clinical
psychologist
Hypotheses
The 4-step approach would reduce the
incidence of gestational diabetes;
The reduction in gestational diabetes would
be mediated through a reduction in maternal
weight gain in pregnancy; and
This would occur without an impact upon
birth weight.
Controls
Routine antenatal care.
This consisted of midwifery, obstetrician
and general practitioner antenatal clinics,
with access to high-risk antenatal clinics if
indicated on medical grounds.
Intervention
Women in the intervention group attended
a study-specific antenatal clinic which
differed in routine care only in the following
four steps.
All other clinic protocols across control and
intervention clinics were identical and
followed The Three Centre Consensus
Statement on Maternity Care
Outcome data
Variables
GDM (%)
Intervention
6
Control
29
P-value
0.04
Weight
gain (kg)
7.0 (0.65)
13.8 (0.67)
<0.001
Birthweight
3.5 (0.07)
3.4 (0.10)
0.162
Outcome data
Variables
GDM (%)
Intervention
6
Control
29
P-value
0.04
Weight
gain (kg)
7.0 (0.65)
13.8 (0.67)
<0.001
Birthweight
3.5 (0.07)
3.4 (0.10)
0.162
IOL : Obese women 4.9 to 9kg
Diet changes
Variables (N)
Fizzy drinks
Water
Fast food
Home cooked meal
Fresh fruit
Fresh vegetable
First visit
(N=63)
61
2
40
23
5
11
Final visit
(N=63)
23
47
21
42
42
42
Quinlivan et al, 2011 Australia
EFFECTIVE
1. Continuity of care
2. Weigh at every antenatal visit
3. Short visit with nutritionist (5 minutes) to review:
•
What did the patient eat the day before?
•
Immediate written feedback on diet
4. Psychological assessment and intervention if
required.
What do other RCT in the literature show?
Is there a pattern?
Can we develop an even simpler
intervention that works?
All RCT
There are currently FOUR RCT of dietary
interventions in obese pregnant women.
1. Wolff et al. (2008) Denmark
2. Thornton et al. (2009) USA
3. Guelinckx et al. (2010) Belgium
4. Quinlivan et al, 2011 Australia
Wolff et al. (2008) Denmark
1. Weight at every
antenatal visit and
discussion of weight
gain by the provider
2. One hour visit with a
dietician followed by
9 x 30 minute visits.
Total of 10 visits.
REPEATED
INTERVENTION
EFFECTIVE
Thornton et al. (2009) USA
1. Continuity of care
2. Initial visit by dietician.
3. Food diary maintained by
patient and discussed at
every antenatal visit by
providers.
REPEATED
INTERVENTION
EFFECTIVE
Guelinckx et al. (2010) Belgium
1. Continuity of care
2. Single visit by a dietician.
SINGLE
INTERVENTION
NOT EFFECTIVE
Quinlivan et al, 2011 Australia
REPEATED
INTERVENTION
EFFECTIVE
Meta analysis – Impact upon
maternal weight gain
Study
N, mean
N, mean
%
(SD); Treatment
(SD); Control
Weight
9.36
ID
WMD (95% CI)
Wolff et al. (2008)
-6.70 (-10.27, -3.13) 23, 6.6 (5.5)
28, 13.3 (7.5)
Thornton et al. (2009)
-9.10 (-10.93, -7.27) 116, 5 (6.8)
116, 14.1 (7.4) 35.75
Guelinckx et al. (2010)
-0.80 (-3.30, 1.70)
65, 9.8 (7.6)
65, 10.6 (6.9)
19.20
Quinlivan et al. (2011)
-6.80 (-8.63, -4.97)
63, 7 (5.2)
61, 13.8 (5.2)
35.68
Overall (I-squared = 89.3%, p = 0.000)
-6.46 (-7.55, -5.37)
267
270
100.00
-10.9
0
Treatment reduces weight gain
10.9
Treatment increases weight gain
Meta analysis – Impact upon
maternal weight gain
Study
N, mean
N, mean
%
(SD); Treatment
(SD); Control
Weight
9.36
ID
WMD (95% CI)
Wolff et al. (2008)
-6.70 (-10.27, -3.13) 23, 6.6 (5.5)
28, 13.3 (7.5)
Thornton et al. (2009)
-9.10 (-10.93, -7.27) 116, 5 (6.8)
116, 14.1 (7.4) 35.75
Guelinckx et al. (2010)
-0.80 (-3.30, 1.70)
65, 9.8 (7.6)
65, 10.6 (6.9)
19.20
Quinlivan et al. (2011)
-6.80 (-8.63, -4.97)
63, 7 (5.2)
61, 13.8 (5.2)
35.68
Overall (I-squared = 89.3%, p = 0.000)
-6.46 (-7.55, -5.37)
267
270
100.00
-10.9
0
Treatment reduces weight gain
10.9
Treatment increases weight gain
The future intervention
1. The intervention needs to be repeated.
2. The intervention can be short.
3. The intervention should include a written element
retained by the woman.
4. The intervention can be undertaken by anyone in the
care team.
A 3 step model
Step 1: Continuity of care;
Step 2: Weight at every antenatal visit;
Step 3: Repeated review by the ANC
provider of a DIETARY DIARY.
The Diary RCT
Enrole:
Women presenting <20 weeks with a BMI>25
Intervention
3 step model versus existing model of care
10 Outcomes:
* Reduce gestational weight gain
* Reduce gestational diabetes (15% to 10%)
Sample size:
N=1450
The DIARY trial
Key elements of the diary...
1. The 3 Do.
2. The 3 Don’t.
3. Diary pages where the
patient writes in the previous
day’s food and drink intake.
4. Space for care provider to
provide written feedback
at each ANC.
Do and Don’t
3 Do...
•Drink water
•Eat fresh vegetables
•Eat home cooked meals
3 Don’t...
•Smoke
•Drink alcohol
•Drink fizzy drinks, cordial
and juices
Thankyou