PARC Services
PARC services support capacity-building, knowledge-sharing and
learning opportunities.
PARC services include providing:
information on physical activity
consultation on physical activity issues
assistance in the preparation of workshops and meetings
review of physical activity-related materials
training for physical activity promoters
managing physical activity programs
PARC Pre-Congress session 2010 International Congress on Physical
activity
Visit www.parc.ophea.net
Sign up for our listserv
Special thanks to:
Dr. Michelle F. Mottola, Ph.D. FACSM Director,
R. Samuel McLaughlin Foundation –
Exercise and Pregnancy Laboratory
University of Western Ontario
London, Ont. N6A 3K7
mmottola@uwo.ca
Purpose of Workshop
1.
To educate & inform women (& men) about the importance
of physical activity during and after pregnancy
2.
To increase understanding of PARmed-X for Pregnancy
3.
To increase knowledge of current research in the area of
physical activity and pre/post pregnancy
4.
To discuss with others ways to promote and disseminate
this information
5.
To provide an opportunity to ask specific questions, and
learn and share with other workshop participants about
existing successful programs
Prenatal physical activity
• Historical guidelines for exercise during
pregnancy
• PARmed-X for Pregnancy
• Research Evidence
• Exercise guidelines
• Safety considerations
• Community resources
In the Past
Prior to 1985
Exercise Guidelines
for women did not exist.
REST!
In the Past
1985  ACOG (American College of Obstetrics & Gynecology)
suggested heart rate should not go over 140 beats per minute
1994  ACOG Ignored heart rate;
Replaced with common sense guidelines
2002  ACOG Ignored heart rate;
Replaced with exercise on all days of week!
www.csep.ca
CSEP & Health Canada (1996; Revised 2002; 2009)
PARmed-X for pregnancy
(Physical activity readiness, medical
prescreening & exercise prescription)
- written for physician/midwife or health care
professional to increase communication
Authors: L.A. Wolfe, Queens & M.F. Mottola, Western
Canadian guidelines for active living during pregnancy
**Joint SOGC/CSEP Clinical Practice Guideline 2003**
Davies et al. 2003; www.csep.ca
** Endorsed by the ACSM – Oct Bulletin 2004
** Endorsed by the CASM – March 2008 – Position Statement
** Used by PARC (OPHEA) – Goodlife Fitness (CANFitPro)
** Used by Middlesex-London Health Unit + Other Health Units
CSEP & Health Canada
(1999)
Active Living During
Pregnancy
Physical activity guidelines
for mother & baby.
Author: Angela Kochan-Vintinner
(Eds. Wolfe & Mottola)
Summary of Canadian
Guidelines
Previously sedentary women with healthy pregnancies can safely
start an exercise program in the second trimester
Women with low risk pregnancies can continue mild to moderate
activity throughout
Mild to moderate aerobic activity within the Canadian guidelines
(PARmed-X for Pregnancy) is considered safe
Muscle conditioning activity with necessary precautions is also
considered safe (consult with a physical activity specialist )
PARmed-X
for Pregnancy
(Physical activity readiness, medical
prescreening & exercise prescription)
• Written for physician/midwife or
health care professional
Authors: L.A. Wolfe, Queens & M.F. Mottola, Western
• 4 page document
• current history of pregnant women &
occupation
- list of contraindications to exercise
- absolute, relative
- Aerobic conditioning guidelines
F. (frequency) 3- 4 times /week
I. (intensity) target HR zones
T. (time) 15 up to 30 minutes
T. (type)
- Muscle conditioning guidelines
& precautions
- Safety considerations & reasons to
consult a physician/midwife/health
care professional
Heart Rates
Mottola et al. 2006 – Med. Sci. Sports Exerc. – new zones
VO2peak Prediction and Exercise Prescription for Pregnant
Women. 38(8):1389-1395.
Target Heart Rate Zones:
20-29 years
Fit – 145 – 160 beats/minute
Unfit – 129 - 144 beats/minute
30-39 years
Fit – 140 – 156 beats/minute
Unfit – 128 – 144 beats/minute
Age
Heart Rate
<20
140-155
20-29
135-150
30-39
130-145
*heart rates if active
New Target Heart Rates
Mottola et al. 2006 – Med. Sci. Sports Exerc. – new zones
VO2peak Prediction and Exercise Prescription for Pregnant
Women. 38(8):1389-1395.
New Target Heart Rate Zones Based on Age & Fitness:
Age 20-29 years
Low
Active
Fit
Target Heart Rate Based on Fitness
129-144
140-155
145-160
Age 30-29 years
Low
Active
Fit
Target Heart Rate Based on Fitness
128-144
130-145
140-156
For Overweight & Obese
Pregnant Women?
• Current guidelines present THR zones of 60-80% of max aerobic
capacity -PARmed-X for Pregnancy
• These women may not be capable of exercise at this intensity
• The ACSM (2005) suggest overweight and obese women initiate an
aerobic exercise program of 20 to 39% of VO2reserve
• Must be medically pre-screened
• Target heart rate zones based on age:
• 20 to 29 years = 102 – 124 bpm;
• 30 to 39 years = 101 – 120 bpm
Davenport, Charlesworth, Vanderpank, Sopper & Mottola 2008.
Appl Physiol Nut Metab 33: 984-89.
Promotion of Physical
Activity During Pregnancy
Pregnancy is time when many women change
to a healthier lifestyle
improve eating habits
quit smoking
stop alcohol use
moderate caffeine consumption
receptive to learning new info
want to be good parents and do the best for their baby
think about active living
Most common
advantages and influences
Most common advantages
• Exercise improves mood
• Increases energy and stamina
Most common normative influences – (influence of people
that have an impact)
• Family members and children
• Not physicians!
Barriers to
obstructing exercise
Physical limitations
Tiredness/fatigue
Time limits
Weight gain
Benefits of Regular
Physical Activity
• help you and baby gain proper amount of weight
• reduce discomforts such as, backaches, leg cramps, constipation,
bloating, and swelling
• Improve mood, energy level and feelings about appearance
• Strengthen muscles and improve blood flow
• Improve sleep
• Help you have an easier, possibly shorter labour
• Help you recover from delivery & return to a healthy weight faster
More benefits
• Helps control blood sugar
• Improves heart and lung health
• Promotes health lifestyle for family
& children through role modeling
Needs for
Pregnant Women
• Benefits of being active during pregnancy
• Guidelines available for exercise during pregnancy (www.csep.ca)
• Identify barriers to being active and ways to overcome them
• Assistance in social support (health care providers, family
involvement, transportation, safety issues, facilities, subsidized
community programs)
Safety Considerations
1.
2.
Choose moderate activities unlikely to cause injury, such as, walking
(most popular), aqua aerobics, swimming, yoga, or a stationary bike
Stop exercising if you feel tired, or are overheated
3.
4.
Drink plenty of water
Wear comfortable clothing that fits well and is supportive
5.
6.
Stop exercising if you feel dizzy, short of breath, pain in your back,
swelling, numbness, sick to your stomach, or if your heart is beating
too fast or at an uneven rate
Stop exercising if you have vaginal bleeding
7.
8.
Eat a well-balanced diet
Avoid center of gravity shifts
9.
Avoid lying on your back for long periods of time
Other Ways to Promote
Active Living
• Muscle conditioning activities – check out cupboard!!
• Increase steps taken per day –
park farther away; take stairs
• Rake leaves; cut grass
• Gardening
• Play with kids!
Prenatal Education
• Exercise education should be incorporated into pre
and post natal care.
• Importance of education and social support.
• Include babies & child care in programs
• Include PAR Q for Pregnancy in information packages
along with brochures on what activities are safe
Community Resources
Where to go for additional information?
Courses/classes
Reading materials
Some new research –
the obesity link
Pregnancy link to obesity in mother and offspring
Risk factors for childhood obesity
Obesity prevention better than treatment??
Fetal Imprinting and maternal environment
Maternal Lifestyle during pregnancy
Some new research –
the obesity link
[Flegal et al. JAMA 2002; 288:1723-7].
Prevalence of Obesity in the U.S:
30% of adults above 20 years age are now obese
60 million people!!
9 million children or teens are overweight!!
Health issues:
• affects all organ systems
• risk factor for hypertension
• type 2 diabetes
• cardiovascular mortality
• dementia
Childhood Obesity
1. increased morbidity
2. adult obesity
3. related adverse metabolic and
cardiovascular problems
4. dyslipidemia tracks from childhood into adulthood
Prevalence of
Obesity in Canada
2004
59% - OW
23% - OB
Katzmarzyk PT. Canadian Medical Association Journal, 2002. Katzmarzyk PT. Obesity, 2008
International
factors
Market
globalizatio
n
National/regional
factors
Community
factors
Educational policies
Public
transportation
Individual
factors
Occupation
Genetic
Transportation policies
Safety
Travel
Urbanization policies
City planning
Health policies
Leisure
Industrialization
Food policies
Food availability
and accessibility
Sports
activities
Media and
advertising
Food
Family policies
Media and
marketing
Cultural policies
Economic policies
Income
Body
image
Adapted from Ritenbaugh C, Kumanyka S, Morabia A,
Jeffrey R, Antipatis V. OITF 1999
Energy
expenditure
Food
intake
Cover page of The Economist, December 13-19th, 2003.
Populations at risk
for weight gain: WOMEN
• Women in reproductive years
• Pregnancy – excessive weight gain
• Post partum – excessive weight retention
• Menopause
• Adolescent females
Obesity/overweight
increases risk for Gestational
Diabetes (GDM) about 17%
(Linne 2004)
Maternal Obesity
Up to 40%
1 in 6 – obese
1 in 3 - overweight
National Geographic 2004
Pregnancy link to Obesity?
Among women of childbearing age, one
potential pathway for obesity development
is excessive pregnancy weight gain and
post partum weight retention
National Geographic 2004
Siega-Riz et al. 2004. Nut Rev 62:S105-11
Risk factors for GDM…..
• No exercise – Watching T.V. (sedentary lifestyle)
• Overweight/obesity;
• Body Mass Index – Weight/Height2 (BMI>25; >30kg/m2)
• GDM in previous pregnancy
• History of Large Babies > 9 lbs
• Family History of Diabetes
• Age
• Ethnicity – Aboriginal, Hispanic, South Asian, African
Offspring …..
• Type 1
• Later in life (type 2)
• Large babies at risk for obesity which
is a risk factor for diabetes
Vicious Circle!!!
Risk Factors for
Childhood Obesity:
• Higher birth weight predicted increased risk
of overweight in adolescence
• Born to a mother with GDM
• Lower birth weight associated with later risk for central
obesity
• Obese mother/ father
• Family life – overeating & sedentary lifestyle
Influence on early
post-natal life
• Infants who were fed breast milk or who were breast fed
longer had lower risk of overweight in adolescence
• WHO breast fed at least 6 months Exclusively!!
• Parental feeding patterns
• Parental activity patterns
• Obese mother – obese child
Obesity prevention better
than obesity treatment??
• Obesity prevention – begin very early in life?
• Obese preschoolers associated with
pre-pregnancy BMI of mother
• Children of obese mothers twice as likely
to be large for gestational age at birth
• Large for gestational age babies more likely
to be obese preschoolers
Whitaker 2004 Pediatrics
Need Obesity prevention
better than obesity
treatment?? Title?
• Prevalence of obesity in children doubled over past 2-3 decades
• Appears to be accelerating
• Obesity & overweight are risk factors for type 2 diabetes
• Type 2 diabetes is no longer an adult disease – happens to younger
population including children
• Interventions (treatments) aimed at school age kids – TOO LATE!!
• PREVENTION!!!! EARLY YEARS??
Impact of maternal &
child health on current
obesity epidemic
Prevention vs. treatment??
Intervention times?
• before conception
• during pregnancy
• early years of child’s life
Awareness:
Living in Balance
Causes:
- input vs output
- accelerated body weight gain
- genetics; metabolic problems
- excessive weight gain during
pregnancy & weight retention
- fetal programming?
EATING
HABITS
ACTIVITY
Programming evidence:
• diabetes during pregnancy
• maternal glucose transferred to the fetus
• large for gestational age infant
• fat cell size and number determined in late pregnancy
• risk of offspring for obesity and type 2 diabetes
• small for gestational age infants
• inadequate maternal nutrition esp. protein
• more at risk for central or truncal obesity
• fat cell size and patterning early post natal life
• problem with cardiovascular risk
Oken & Gillman, 2003 Obesity Res
Fetal Origins of Obesity:
Trouble on both sides of the birth weight spectrum
• in utero environment has profound effect on lifelong health
• higher birth weight = higher BMI
• lower birth weight = higher BMI
- Assumption of patterning
- Stimulus at critical
period of development
has lasting effect
BMI
Oken & Gillman 2003; Catalano 2006
Birth
Weight
Birth weight/fat deposits
Mismatch
- under-nutrition fetal environment
- catch-up growth postpartum – rapid weight gain
- abdominal obesity
- large babies
- large adults
BMI
Birth Weight
Fetal
Programming??
• Growing evidence that prenatal
environment impacts on chronic
disease risk in infant
• increased fat mass accompanied
by glucose intolerance; insulin
resistance; diabetes; CV problems
National Geographic 2004
At Birth
Overworked
pancreas
High
Insulin
Fat Deposits
High Sugars
Baby Low
Blood Sugars
Birth Canal
Rat Study
(Bayol et al. 2007):
Maternal ingestion of “junk
food” (heavily processed,
hyper-energetic) during
pregnancy and lactation
may increase junk food
preference of the offspring
and may increase the
propensity for offspring
obesity.........
GDM
In high-risk groups, GDM is
considered a significant initiating
factor in the type 2 diabetes/obesity
epidemic and thus prevention may
lead to decreased rates of type 2
diabetes in successive
generations!!
(Dyck et al. 2002)
Rat Study
(Bayol et al. 2007):
If we restore the balance, can obesity and diabetes be prevented
in future generations??
Eating
Habits
Activity
burrito
fruit
steak
cheese
pasta
potato
butter
2004
1954
2004
1916
1955
1950’s
1900
How can we make a
difference during
pregnancy??
How can we make
a difference in infancy?
Position of Uterus against
Inferior Vena Cava
INFERIOR VENA CAVA
STANDING
SUPINE
NO RESTRICTION OF
BLOOD FLOW
BLOOD FLOW MAY BE
RESTRICTED
NORMAL
DIASTASIS RECTI
Correct Posture in standing position
Keep the shoulders back; do
not round shoulders forward
Be careful
of (posterior
pelvic tilt)
Bend the knees slightly
Keep the neck straight and
the chin held up
Lift up through the chest
cage
NEUTRAL
PELVIC
ALIGNMENT
Distribute the body
weight on both feet
Daily activity before program:
Pedometer Count:
5825.4 ±1794
Steps/day
Activity Index
< 5000
Sedentary
5000 - 7499
Low Active
7500 - 9999
Somewhat
Active
 10,000
Active
>12,500
Highly Active
Tudor-Locke & Bassett 2004
Walking Program:
• based on pedometer steps
• 25 min/session; 3-4 X week
• 2880±297 steps
• add 2 min/wk until 40 min
• 4854±559 steps
• target HR ~ 118±6.8 bpm
5800 + 4800 = 10,300 steps per day (end of program)
Blood sugars monitored once per week – pre & post exercise with
glucometer
Davenport et al. 2008 Appl Physiol Nutr Metab 33:511-7.
Walking effect
on blood sugars?
Capillary sugar – pre exercise (43 observations)
One hour after eating = 7.8 ± 1.4 mmol/l
Capillary sugar – post exercise
5.3 ± 1.1 mmol/L
Walking may help prevent insulin injections & help
control capillary blood sugars
RESEARCH QUESTIONS??
PREGNANCY
EVIDENCE-BASED
GUIDELINES!!!
EXERCISE
Activity - Postpartum
Rediscovering the “M” in “MCH”:
maternal health promotion after
childbirth
The science and practice of health
promotion after childbirth is less well
developed except for breast
feeding and family planning
Walker LO, Wilging S. JOGNN 2000;29:229-236
Why should we promote
health in the postpartum?
Reduce the risk of developing
heart disease, obesity and other
lifestyle-related diseases.
Improve women’s health and
well-being in the immediate
postpartum period.
Summary of
Preliminary Data
• Post-partum women who exercised during pregnancy can maintain
their fitness levels at 2 months post delivery
• At 2 months post-partum, active women have lower resting blood
pressure than active non-pregnant control women
• Major activity is walking up to 60 minutes
with/without stroller by 2 months post-partum
• Most appear to have no problem with breast
feeding by 2 months post-partum
Guidelines
• Guidelines exist for exercise
during pregnancy, but relatively
little attention has been given to
exercise in the postpartum
period, and specific guidelines
for exercise in the postpartum
period are essentially nonexistent.
Regular physical activity essential to
the health of women throughout
their life-span.
Benefits of exercise in the
postpartum period
Improved fitness
Less urinary stress incontinence
Less lactation-induced bone loss
Less postpartum weight retention
Improved psychosocial well-being
Barriers
Women are less likely than men to participate
in vigorous, regular exercise.
Exercise may be further compromised by
pregnancy and recovery from childbirth
Other barriers….
Downs & Hausenblas 2004. J.
MidwiferyWomens Health 49:138-44)
Barriers to activity for
new moms
? others ?
Barriers to activity
for new moms
Better understanding of
women’s health promotion in
the 1st postpartum year is an
essential step in addressing this
neglect in maternal health.
Influence on
early post-natal life
• Infants who were fed breast milk or who were breast
fed longer had lower risk of overweight in adolescence
• Parental feeding patterns
• Parental activity patterns
• Obese mother – Obese child
• Maternal influence as care-giver
Guidelines form American College
of Obstetricians and Gynecologists
for exercise during postpartum
period, 2003
• Rapid resumption of activities has no adverse effects,
but a gradual return to former activities is advised
• Medical Screening – PAR Q Med X for pregnancy:
www.csep.ca to download four page document
• Guidelines are the same for adult as for pregnant or
postpartum woman: from Canada’s Physical Activity
guide www.paguide.com
Exercise in
postpartum period
• Many physiological and morphological changes
remain from four to six weeks after delivery
• Is very individual – some women can begin back as
soon as two days after birth
• Hormones fluctuate leading to body imbalances
Activity & breastfeeding
• Important to continue breastfeeding
• Obese women tend to breastfed less often and shorter
duration
• Best to nurse before exercised to avoid discomfort
from engorged breasts.
• Avoids potential problems with increased acidity of
milk secondary to any build up of lactic acid
Important exercises
Kegel exercises
Pelvic tilts
Shoulder rotations
Half crunches
Walking
What feels right for new mom
Examples of
post-natal muscle
conditioning exercises
Using baby for post-natal
activities
Using baby as resistance tool
(carefully!!)
Have fun interacting with baby
when doing push-ups
(Active Living During Pregnancy, CSEP, 1999)
Returning to activity
• Return to being active after pregnancy
has been associated with decreased
postpartum depression
• Only if exercise is stress relieving and
not stress provoking
BJ Sports Medicine 2003 :37
Programs and Learnings
“from the field”
We want to hear from you.
Do you have any programs, resources to share?
Add to our resource package.
Group Work
• Discuss ways to implement the learnings
from the workshop into programming that
you already do.
• Are there any ideas for new programs that you
could create?
• What are some ways to overcome some of the
barriers to being active?
Evaluation time
Thank you for your attention and participation –
we value your feedback!
PARC’s contact information:
www.ophea.net/parc
- soon to be
http://parc.ophea.net
Louise Daw
PARC Consultant
louise@ophea.org
519.646.2121