Prenatal lifestyle choices and implications
for future disease risk
Christina Gayer Campbell, PhD, RD Lyndi Buckingham-Schutt, RDN
Associate Professor of Nutrition Doctoral Candidate
Uelner Professor of Food Science and Interdepartmental Graduate Program in
Human Nutrition
Nutritional Sciences
Iowa State University Iowa State University
[email protected]
[email protected]
Learning Objectives
• Identify anthropometric and metabolic
outcomes associated with future disease risk
for mother and child.
• Describe the role of nutrition, physical activity
and sedentary behavior in the prevention of
maternal and child future disease risk.
• Address the role of the RDN in prenatal care.
“Pregnancy is a stress
test for future
chronic disease”
D. Krummel, Ph.D. University of Cincinnati
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“Pregnancy is a stress
test for future
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Crane, White, Murphy, Burrage, & Hutchens, 2009; Phelan, et al., 2011;
Crozier, et al., 2010; Mamun, et al., 2010
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Carreno, et al., 2012
2009 IOM GWG Guidelines
Institute of Medicine. “Weight Gain During Pregnancy: Reexamining the Guidelines”. May, 2009
51.8%
67.2%
84.1%
Data from PIN3 study (married, college educated,
non-smokers, high-income households.
Deierlein et al Pediatr Obes 2012.
Prevention of Excessive Gestational
Weight
Gain
(GWG)
Diet:
– Calorie & CHO restriction1
– Low glycemic diet2
– Counseling3-4
Physical Activity:
– Benefits of physical activity (PA) during pregnancy have been
well documented
– Only 16-25% of women meet 2008 DHHS prenatal PA
recommendations5-7
– Little is known about behavior throughout the rest of the day
1
Mottola, et al., 2010; 2Rhodes, et al., 2010; 3Kinnunen, Raitanen, Aittasalo, & Luoto, 2012; 4Guelinckx, Devlieger, Mullie, & Vansant, 2010;
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Evenson & Wen, Prev Med., 2010; 6Evenson & Wen . Prev Med., 2011; 7Evenson , Savitz, & Huston. Paediatr Perinat Epidemiol., 2004
Effectiveness of lifestyle interventions
• Meta-analysis of 34 studies RCT
– Any intervention (diet, PA, mixed)
1.42 kg reduction (-1.89 to -0.95 kg; 95% CI) vs control
– Diet most effective
3.84 kg reduction (-5.22 to -2.45 kg; 95% CI)
– PA
0.72 reduction (-1.20 to -0.25 kg; 95% CI)
Regardless of lifestyle intervention,
no significant differences on adherence to IOM guidelines
Thangaratinam et al. BMJ 2012
Sedentary Behavior (SB)
• SB in non-pregnant adults:
– Metabolic syndrome1-4
– Cardiovascular risk5
– Insulin resistance6
• SB during pregnancy:
Lower birth weight7
Abnormal glucose tolerance8-9
Increased risk for gestational diabetes mellitus9-11
Decreased insulin sensitivity and increased insulin
secretion12
– Excessive gestational weight gain13
–
–
–
–
1
Ford, Kohl, Mokdad, & Ajani, 2005; 2Healy, et al., 2008; 3Hsu, et al., 2011; 4Wijndaele, et al., 2009, 5Manson, et al., 2002; 6Helmerhorst et al.,
2009; 7Both et al, 2010; 8Gollenberg et al., 2010; 9Oken et al.,, 2006; 10Zhang, Solomon, Manson, & Hu, 2006; 11van der Ploeg, et al., 2011;
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Gradmark, et al., 2011; 13Jiang, et al., 2012
Daily Activity: min or hrs/day
(% of day) Week 35
Week 18
VPA*
0%
MPA
3%
LPA*
13%
VPA*
0%
OBT
2%
Nighttime
Sleep
29%
MPA
3%
OBT
2%
LPA*
11%
Nighttime
Sleep
28%
<7hrs: 63%
<7hrs: 61%
SED
53%
SED
55%
Di Fabio et al., IJBNPA 2015;12:27
Effectiveness of lifestyle interventions
Meta-analysis of 34 studies RCT
– Any intervention (diet, PA, mixed)
1.42 kg reduction (-1.89 to -0.95 kg; 95% CI) vs control
Critical need for randomized-controlled trials using
– Diet most effective
a behavioral
theory as the foundation of the study
3.84 kg reduction (-5.22 to -2.45 kg; 95% CI)
design
to evaluate effectiveness of prenatal lifestyle
– PA
interventions
0.72 reduction (-1.20 to -0.25 kg; 95% CI)
Regardless of lifestyle intervention,
no significant differences on adherence to IOM guidelines
Thangaratinam et al. BMJ 2012
What is the Blossom Project?
• It began as a personal question in 1997…
• How much exercise could I do while pregnant and my
baby would be “safe”?
In 2008, began quantifying prenatal diet, PA, maternal
and infant outcomes…
The goal now is to develop effective lifestyle strategies
that can be implemented “during pregnancy” to prevent
maternal complications to promote a healthy future for
mother AND baby
The Blossom Project Online
Overall purpose:
To increase adherence to prenatal physical activity
recommendations and thereby prevent excessive gestational
weight gain
Approach:
Provide previously inactive pregnant women access to an
interactive website based on Social Cognitive Theory
14
Blossom Tips
15
Blossom Journal
16
Blossom Community
17
Randomized-controlled Trial
Enrolled
N=51
Completed
study
n=45
Control
n=21
Blossom Tips
Drop
n=6
Intervention
n=24
Blossom Journal
Blossom
Community
High risk: 1
Stress: 1
Lost to follow-up: 3
Birth defects: 1
Study Design
Wks 10-14
Wks 24-26
Wks 34-36
•Data collection
•OGTT
•Data collection
•Enroll
•Medical hx questionnaire
•Baseline data collection
Maternal weight at first
prenatal visit
All participants
Delivery
1-month pp
•Maternal weight
•Website surveys
•Infant weight,
length, body comp
Birth outcomes:
•Weight
•Length
•Head circumference
•APGAR scores
•Gestational length
Maternal weight at last
prenatal visit
Results
Group
Control
MVPA in
20-min bouts
Intervention
MVPA in
30-min bouts
NS
*P = 0.005
*P = 0.0008
NS
NS
Baseline
Wk 24-26
Wk 34-36
Baseline
Wk 24-26
NS
Wk 34-36
MVPA: Moderate-vigorous physical activity
*Also significantly different within group
NS: Not significantly different
from baseline, P < 0.05
Smith et al., JPAH in press
Results
*Significantly different between groups, P < 0.0125.
Smith et al., JPAH, 2016
Summary
• Participants in the intervention group walked
significantly more
• A third of all participants met weekly goal
• Women in the intervention group
compensated and ate more
• No differences in weight gain between the
groups
• More gained in excess in the intervention
group
Yes, they walked more but what about
the rest of the day?
Figure 3. Intentional walking (bouts
≥20 minutes) for INT was greater at
mid-pregnancy (P<0.01) and
late-pregnancy (P=0.07)
Metabolic Impact
positive relationships between measures of
glucose intolerance and sitting in bouts longer
than 60 minutes
• fasting blood glucose
R2 = 0.2997, P<0.0002
• 1-hr blood glucose following a 75 g OGTT
R2 = 0.125, P<0.023
The Blossom Project:
“Be Well”
Behavioral Wellness Study in pregnancy
• Comprehensive behavioral lifestyle intervention:
• Personalized diet plan
• Physical activity goals
• Behavioral modification
• Aim of our study is to provide an intensive lifestyle intervention to
prevent excessive gestational weight gain, decrease postpartum
weight retention, increase physical activity, improve mental-well
being in a pregnant population and improve fetal outcomes.
Be-Well Preliminary Results
Be-Well Preliminary Results:
Weight gain:
Physical activity:
Baseline
Data reported in median (range) and average ± SD.
Third Trimester
Buckingham-Schutt and Campbell, 2016, unpublished data.
Conclusions
• Pregnant women spending >70% of their time
awake in sedentary behaviors
• Behaviorally-based website is an effective tool
to increase physical activity with no GWG
effect
• Compensatory behaviors resulted with
increased energy intake and prolonged sitting
• Sedentary behaviors associated with negative
metabolic outcomes
• Lifestyle intervention may reduce excess
gestational weight gain
Bottom line
• Current physical activity recommendations (150
minutes/week) are not based on prenatal
outcomes
• Dose of physical activity needed to promote
optimal health will depend on outcome
• It is not as simple as asking women to walk
more…different messages will be needed.
• An intervention focused on reducing CHO and
increasing PA utilizing MI with an RDN holds great
promise!
Brainstorm ideas for practice
Collaborators:
Lorraine Lanningham-Foster, PhD
Laura Ellingson, PhD
Philip Dixon, PhD
Spyridoula Vazou, PhD
Amy Welch, PhD
Greg Welk, PhD
Students:
Courtney Blomme, RDN
Lyndi Buckingham, RDN
Diana Di Fabio, MS, RDN
Stephanie Kratzer, MS, RD
Caroline McKinney, RDN
Katie Smith, PhD, RDN
Each year, 6-8 undergraduate students assist with data collection, entry and organization.
2015-16: Rachel Dalton, Ali Jaeger, Tessa James, Jessie Lundberg, Chloe Lundquist,
Macy Mears, Jackie Pedersen, Nina Streauslin
We couldn’t do any of this work without their contribution!
Self-determination theory
• Assumption that all individuals have natural, innate,
and constructive tendencies to develop a better sense
of self.
• Extrinsic Motivation: performance of an activity in
order to attain some separable outcome
• Intrinsic Motivation: doing an activity for the
personal satisfaction that are freely and willfully
chosen.
Ryan and Deci, 2000
SDT Continuum
• Three basic needs for satisfaction: Autonomy, competence,
relatedness
Motivational interviewing
• A directive, client-centered counseling style for eliciting
behavior change by helping clients to explore and resolve
ambivalence
• Supports change in a manner consistent with the person’s
own values and concerns
• Three essential elements:
– Conversation about change (counseling, relatedness)
– Collaborative (person-centered, honors autonomy)
– Drawing out, rather than imposing ideas & building confidence in
ability to change (competency)