Improving Mother and Infant Health Outcomes by Involving Primary Care Dietetic Practice. Highlights from an Umbrella Review

13/09/2019

Improving mother and infant health outcomes by involving primary care dietetic practice.

Highlights from an Umbrella Review

Cheryl Watterson, Clare Collins, Lesley MacDonald, Melinda Hutchesson, Vanessa Shrewsbury, Lisa Vincze, Nicola Heslehurst, Maxime Gelens. August 2019

What’s the problem?

 pre-pregnancy underweight, overweight and obesity Mamun 2011: Brisbane, Qld cohort 6632 women in 1981-1983. Wah Cheung 2018: Western Sydney cohort 6175 women in 2014-2016. gestational weight gain (inadequate or excessive) Goldstein 2017: 23 cohort studies, >1 million women. Mamun 2011: Brisbane, Qld cohort 6632 women in 1981-1983. gestational weight gain in 1st and 2nd trimester Broskey 2017: China 16,218 mother-child dyads  pre-pregnancy obesity added to excess GWG  Mamun 2011: Brisbane, Qld cohort 6632 women in 1981-1983. increases in weight/BMI between pregnancies Ron 2015; Meta-analysis of 10 observational studies with 116735 women.  maternal obesity exacerbates the intergenerational cycle of obesity.  Deraik 2015: Swedish intergenerational retrospective cohort 26561 mothers and 1st born daughters

Can primary health care address these health burdens with effective nutrition interventions before, during or after pregnancy?

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BMI and small for gestational age, 2016

Are there effective nutrition interventions before, during or after pregnancy that primary care dietitians can utilize to improve mother and infant health outcomes? Modifications of UR objectives for this presentation

Inclusion criteria Synthesis of the evidence (PICOS) Women, before, during, What is the evidence after pregnancy quality?

Diet only, Diet + PA/ Is the evidence consistent? other The objective of this umbrella review is to determine the characteristics of dietary interventions delivered any time Standard care What are the important before, during or after pregnancy for women living in outcomes? developed countries, identified in quantitative systematic reviews as effective for improving mother and infant MIHO + weight related Is the evidence health outcomes and feasible for translation into practice. outcome eg GWG/ transferrable to your PPWR setting? RCT

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Pregnancy stage Systematic Review Weight related finding

Preconception Opray 2015 No studies found1. Price 2018 (excluded Modest weight loss of 4-6kg over due to inclusion of non- short duration interventions RCT studies) improved fertility, noincrease in pregnancy loss, no evidence found on other reproductive outcomes. Weight loss with bariatric surgery Results: prior to pregnancy 22 to 28 kg2. Pregnancy 12 systematic reviews GWG decreased -1.8 to -0.7kg3

Postpartum/ 12 postpartum reviews PPWR (any BMI) -3.3 to -1.63 kg, Interconception For owt/ obese -4.2 to -1.56 kg4.

1 Opray 2015, 2 Price 3 Farpour-Lambert 2018, 4 Dodd 2018

Systematic review & BMI Quantitative Results quality rating

Muktabhant 2015 A Any BMI -3.36 to -0.24 kg, 3 studies, 444 participants, I2 = 76% RR 0.80 (0.73 to 0.87), 24 RCT, 7096 participants 1

Shepherd 2017 A Any BMI MD -0.89 (-1.39 to -0.40 kg), 16 RCT, 5052 participants, I2 = 48% 2

Thangaratinam 2012 A Any BMI - 2.09 to – 0.71 kg, 30 studies, 3140 participants, I2 = 76%, diet only: -5.22 to -2.45kg, 10 studies, 2560 participants, I2=92%3

Do nutrition Yeo 2017 A OW/OB --2.55 to -0.86, 32 studies, 5869 participants, I2 = 83% ( 26/32 studies interventions were diet &PA interventions) during Yeo 2017 A OW/OB -7.01 to -0.75, 7 studies, 2561 participants, I2 = 94% ( maternity pregnancy service providers + 5/7 studies maternity providers supported by reduce excessive dietitian (3)/ other (2)) GWG? Lau 2017 B OW/OB -1.07 to -0.20 kg, 7 studies, 1652 participants, P=0.04, I2 = 14%

Rogozińska 2017 C Any BMI -0.92 to -0.48 kg, 33 studies, 11, 410 participants, I2 = 0%

Choi 2013 D OW/OB -1.76 to -0.06 kg, 7 studies, 721 participants, I2 = 8% (2/7 studies were PA only)

Agha 2014 D Any BMI -3.12 to -0.21 kg, 14 studies, 1771 participants, P=0.03, I2 = 86%

O’Brien 2016 D Any BMI -2.39 to 0.11 kg, 4 studies, 446 participants, P=0.03, I2 = 42%

1 High quality evidence 2 Moderate quality evidence 3 Moderate quality evidence (GRADE)

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Do nutrition interventions during pregnancy reduce the incidence of GDM?

Systematic review & quality rating Population Intervention type Quantitative Results

Bennett 2018 A Women between 9-28 weeks Diet only aimed to prevent/ 44% reduction, P=0.009, 9 studies, 2673 participants, I2=53% gestation reduce excessive GWG lifestyle interventions had no effect on GDM incidence .

Shepherd 2017 A Women, < 20 weeks gestation Diet & PA 15% reduction trend, P=0.07, 19 studies, 6633 women, I2 = 42% (GRADE: MODERATE quality)

Madhuvrata 2015 C Women with GDM risk factors, Diet only Diet 7% versus standard care 18%, P=0.009 < 20 weeks gestation 3 studies, 455 participants, I2 = 26%

Thangaratinam 2012 A Women, mainly overweight Diet only 61% reduced risk, P=0.001, 3 studies, 409 participants, I2 = and obese 21% (GRADE: LOW quality)

Do nutrition interventions during or after pregnancy reduce PPWR?

Systematic review & R- BMI Intervention Quantitative Results AMSTAR quality rating

type timing

Lim 2019 D Any BMI Diet (1), PA (13), D&PA Postpartum only Weighed less at end of the intervention: MD, -2.24 kg, 23 studies, 1796 participants, I2 = 80%. (19) Health provider led interventions : -3.20, p=0.01, 7 studies, 410 participants, I2 = 52%

Dodd 2018 B BMI > 18 D&PA Postpartum only Weighed less at end of the intervention: -3.3 to -1.63 kg, 12 studies, 1156 participants, I2 = 86% At 12 months postpartum, weighed less: -3.89 to -0.93, 4 studies, 405 participants, I2 = 31%

Michel 2018 A Any BMI Diet only (1), PA only Pregnancy only Weighed less at end of the intervention: MD, -0.73kg, P=0.015, 14 studies, 3661 participants, I2 = (1), D&PA (12) 53%

Dalrymple 2018 B OW/OB D&PA Pregnancy only 1/3 studies had sign. effect on PPWR at 6 months, 3 studies, 504 participants, 18 studies, 2559 participants

Diet (1), D&PA (2) Pregnancy & 1/3 studies had sign. effect on PPWR at 6 months, 3 studies, 270 participants Postpartum

Diet (4), D&PA (8) Postpartum only 7/ 12 studies had sign. effect on reducing PPWR at 12 months (4 trials) or at the end of the intervention (3 trials) 12 studies, 1785 participants. 6/7 of the effective trials were of short duration (10-16 weeks).

Goveia 2018 Any BMI + D&PA Postpartum Weighed less at the end of the intervention -0.55 to -1.03, 8 studies, 1645 participants, I2 = 10% previous GDM

Sherifali 2017 B Any BMI D&PA eHealth Postpartum -3.81 kg to -1.28 after 3-12 mths, 4 studies, 162 participants, I2 = 4%

Nascimento 2014 C Any BMI Intensive diet & PA Postpartum -5.15kg to -3.45kg, 6 studies, 267 participants, I2 = 0%

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Do nutrition interventions in women with previous GDM reduce the incidence of T2DM?

Combined diet and physical activity interventions in the first year after childbirth may be effective in reducing the incidence of T2DM for women with a history of GDM – Goveia 2018

Song 2018 suggests that T2DM prevention occur within 3 years of the index pregnancy.

Diet only or diet and PA interventions are effective Evidence strength and Diet only or diet and PA Evidence strength and quality (GRADE) interventions not effective quality (GRADE) Gestational weight gain Moderate 2

GDM trend lower Moderate 2

Caesarean section High to moderate 1,2, 3, 4, 5 Perineal trauma 2 Moderate significantly lower Macrosomia trend lower Moderate4 Postpartum haemorrhage 5 Moderate no effect Neonatal RDS significantly lower High to moderate1,4 Induction of labour 5 Moderate no effect Large Gestational Age trend lower Moderate5 Small Gestational Age 5 Moderate no effect Shoulder dystocia significantly lower Moderate 5 Refs: 1 Farpour-Lambert 2018; 2 Shepherd 2018; 3 Rogozińska 2017, 4 Muktahant 2015, 5 Thangaratinam 2012

For which mother and infant health outcomes is there high to moderate quality evidence of an effect /no effect?

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What these studies add to our understanding - before pregnancy

Bariatric surgery prior to pregnancy results in Take a life course Preconception diet 2 However, there is much greater weight loss approach : intervention results in There is no evidence at international interest in than non-surgical wt loss engage patients before, modest weight loss this stage that diet only providing an evidence techniques3. It appears during early pregnancy which may improve interventions before base for directed to improve pregnancy and after pregnancy. fertility and not increase pregnancy improve preconception health outcomes but may pregnancy complications. raise the topic of mother and infant health programs (including increase risks for the No evidence to date if pregnancy intention with outcomes beside appropriate weight mx, foetus4. No evidence on maternal and/or infant one key question: “ fertility1. improved diet quality the optimal amount and health outcomes are Would you like to and physical activity)2. method of wt loss for improved3. become pregnant in the obese women who are next year? 5. planning pregnancy.

What these studies add to our understanding- during pregnancy

Pregnancy diet interventions targeting GWG improve health outcomes for Pregnancy diet interventions with mothers and their infants: GWG, reduce moderate kJ restriction are safe and caesarean section; shoulder dystocia; effective in pregnancy 2,3. Diet alone interventions to reduce GWG are more effective than standard care in neonatal respiratory distress syndrome and Consider starting primary care diet may reduce the incidence of GDM, LGA reducing GDM incidence, although the Bennett 2018 1, 2 interventions early in pregnancy to avoid effect varies by BMI and region– (high to moderate evidence) . excessive/ inadequate GWG and the Include mother and infant health outcomes associated risk of LGA or SGA infants 4. in dietetic practice.

Health professionals as intervention providers achieve better weight loss for women during and after pregnancy than non-health professionals - Yeo 2017, Lim 2019 Multidisciplinary teams supported by efficient referral pathways and professional development across primary and secondary health care may be effective in managing GWG 5.

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Combined diet and physical activity No evidence to date that postpartum diet Health professionals as intervention interventions provided for postpartum and physical activity interventions providers achieve better weight loss for women effectively reduce PPWR improve health outcomes in a subsequent women during and after pregnancy than (Moderate evidence). No evidence to pregnancy1. non-health professionals 4,5. Consider date that weight loss can be maintained A life-course approach to supporting developing proficiency in maternal long term1. Consider intervention types women and their families may achieve nutrition and weight management that support long term weight loss2. better health outcomes3. interventions 6, Swan 2018.

There are difficulties in engaging postpartum Women with GDM Hx may benefit from a women in diet and physical activity combined diet and physical activity program interventions1, 4. Goveia 2018. Whether face-to face formats deliver better GWG/ PPWR than technology formats currently Consider women’s experiences and needs when Consider offering a lifestyle prevention lacks clear evidence - Lau 2017 , Lim 2019 implementing strategies to promote engagement programme within the 1st year postpartum and with primary care health providers7. no later than 3rd year postpartum Goveia 2018,Song Whether PPWR can be targeted in the pregnancy 2018. only or pregnancy-postpartum period also For example, support obese women to achieve currently lacks clear evidence9. Refer 3, Hanson 2015. exclusive breastfeeding for improved early Consider individualised, intensive childhood growth, refer for lactation support 8. multidisciplinary intervention 2, 6.

What do these studies add to our understanding- after pregnancy?

Acknowledgements

Professor Clare Collins, Dr Lesley MacDonald, Dr Melinda Hutchesson, Dr Vanessa Shrewsbury, Dr Lisa Vincze, Dr Nicola Heslehurst, Ms Berit Follong and Ms Maxime Gelens. School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, Australia, Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Callaghan, Australia.

[email protected]

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Extra slides to presentation To support dietitians in primary care settings to contribute their expertise to improving mother and infant health outcomes.

Why should dietitians do this?

• Diet interventions are the most effective - Thangaratinam 2012 • Interventions based on theoretical models have no evidence of effectiveness Nutrition Care Process and Model benefits: • Efficient screening and referral system across maternity health care providers • People-centred care- Bennett 2018 • Use of concise language- emphasize knowledge gained and behavior changes • Incorporate an outcomes management system: • to demonstrate impact of nutrition care • to benefit your professional development and reflective practice • to report quality measures to patients, other health providers and help inform health service change.

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Why should dietitians do this?

• Target overweight, obese and underweight, women with previous or risk factors for GDM or pre- eclampsia, women with comorbidities: anaemia, hypertension, severe energy restricted diets, poor diet quality eg: low calcium intake, previous excessive GWG at the appropriate stage Who to • Take a life course approach 1: • engage patients before, during early involve? pregnancy and after pregnancy. • raise the topic of pregnancy intention with one key question: “ Would you like to become pregnant in the next year?”- Bateson and Black 2018 • make PPWR interventions available to start immediately after pregnancy good referral systems between primary care and maternity care services.- Dennison 2019 • Collaborate with other disciplines, involve other dietitians, shared antenatal care GPs, maternity services (midwives, obstetricians), exercise physiologists, lactation consultants, diabetes and other chronic disease services. Yeo 2017, Thangaratinam 2012, WHO principles of perinatal care, Hanson 2015.

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• Personalised diet + physical activity in preconception obese women. • Consider VLED, bariatric surgery, aim >7-10 % body wt, restore diet quality + micronutrient supplement before conception. • Personalised diet only interventions in pregnancy lower GWG, reduce the risk of GDM- Bennett 2018 • Personalised diet + physical activity to reduce PPWR, within 1st year. • Consider breastfeeding requirements of approximately 7600kJ. Provide follow-up each year. • Moderate kJ restriction based on individual requirements in 1st and 2nd trimester, 180 grams carbohydrate minimum- Thangaratinam 2012 • Dietary pattern aimed at reducing insulin resistance- UK Diabetes 2018 • Support self-efficacy with SMART goals, food diaries, menu planning, recipes, food What works? literacy etc, and regular feedback

How to implement effective practice

• Pre-pregnancy obesity is best treated before conception or during the interconception period. • PPWR- calorie reduction of 500kcal/day, 12 week intervention of 0.5 kg/ week weight loss. Weight loss maintenance follow up to 12 months and beyond. • Beware of attrition barriers for postpartum women, develop flexible woman-centred multimodal interventions. • Consider eHealth technologies, only endorse safe and effective eHealth apps. Get regular feedback about patient engagement with the technology. (Sherifali 2017)

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When and Where to • Directed preconception health programs deliver maternity (including weight mx, diet quality and physical nutrition interventions? activity) 1 • multidisciplinary delivered in primary care setting • GWG interventions in early pregnancy • Diet only intervention delivered in primary care setting with handover to maternity services around 16 weeks gestation • PPWR and T2DM prevention diet and PA +/- breastfeeding interventions starting seamlessly after childbirth • multidisciplinary delivered in primary care setting

“Think Nutrition First” 2015 21