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Dr. Michelle F. Mottola, Ph.D. FACSM Director, R. Samuel McLaughlin Foundation – Exercise and Pregnancy Laboratory University of Western Ontario London, Ont. N6A 3K7 Special thanks to:

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

Historical guidelines for exercise during pregnancy PARmed-X for Pregnancy Research Evidence Exercise guidelines Safety considerations Community resources Prenatal physical activity

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! In the Past

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; ** 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)

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 ) Summary of Canadian Guidelines

(Physical activity readiness, medical prescreening & exercise prescription) Written for physician/midwife or health care professional Authors: L.A. Wolfe, Queens & M.F. Mottola, Western PARmed-X for Pregnancy

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

Mottola et al – Med. Sci. Sports Exerc. – new zones VO2peak Prediction and Exercise Prescription for Pregnant Women. 38(8): Target Heart Rate Zones: years Fit – 145 – 160 beats/minute Unfit – beats/minute years Fit – 140 – 156 beats/minute Unfit – 128 – 144 beats/minute AgeHeart Rate < *heart rates if active Heart Rates

Mottola et al – Med. Sci. Sports Exerc. – new zones VO2peak Prediction and Exercise Prescription for Pregnant Women. 38(8): New Target Heart Rate Zones Based on Age & Fitness: Age yearsTarget Heart Rate Based on Fitness Low Active Fit Age yearsTarget Heart Rate Based on Fitness Low Active Fit New Target Heart Rates

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 VO 2reserve 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 For Overweight & Obese Pregnant Women? Davenport, Charlesworth, Vanderpank, Sopper & Mottola Appl Physiol Nut Metab 33:

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 Promotion of Physical Activity During Pregnancy

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! Most common advantages and influences

Physical limitations Tiredness/fatigue Time limits Weight gain Barriers to obstructing exercise

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 Benefits of Regular Physical Activity

Helps control blood sugar Improves heart and lung health Promotes health lifestyle for family & children through role modeling More benefits

Benefits of being active during pregnancy Guidelines available for exercise during pregnancy ( 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) Needs for Pregnant Women

1.Choose moderate activities unlikely to cause injury, such as, walking (most popular), aqua aerobics, swimming, yoga, or a stationary bike 2.Stop exercising if you feel tired, or are overheated 3.Drink plenty of water 4.Wear comfortable clothing that fits well and is supportive 5.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 6.Stop exercising if you have vaginal bleeding 7.Eat a well-balanced diet 8.Avoid center of gravity shifts 9.Avoid lying on your back for long periods of time Safety Considerations

Muscle conditioning activities – check out cupboard!! Increase steps taken per day – park farther away; take stairs Rake leaves; cut grass Gardening Play with kids! Other Ways to Promote Active Living

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 Prenatal Education

Where to go for additional information? Courses/classes Reading materials Community Resources

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

[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 Some new research – the obesity link

1.increased morbidity 2.adult obesity 3.related adverse metabolic and cardiovascular problems 4.dyslipidemia tracks from childhood into adulthood Childhood Obesity

Katzmarzyk PT. Canadian Medical Association Journal, Katzmarzyk PT. Obesity, % - OW 23% - OB Prevalence of Obesity in Canada

Adapted from Ritenbaugh C, Kumanyka S, Morabia A, Jeffrey R, Antipatis V. OITF 1999 I nternationalNational/regional CommunityIndividual factorsfactorsfactorsfactors Market globalizatio n Industrialization Media and marketing Educational policies Transportation policies Urbanization policies Health policies Food policies Family policies Cultural policies Public transportation Safety City planning Food availability and accessibility Media and advertising Income Occupation Leisure Sports activities Genetic Energy expenditure Food intake Food Body image Economic policies Travel

Cover page of The Economist, December th, 2003.

Women in reproductive years Pregnancy – excessive weight gain Post partum – excessive weight retention Menopause Adolescent females Populations at risk for weight gain: WOMEN

Obesity/overweight increases risk for Gestational Diabetes (GDM) about 17% Maternal Obesity Up to 40% 1 in 6 – obese 1 in 3 - overweight (Linne 2004) National Geographic 2004

Among women of childbearing age, one potential pathway for obesity development is excessive pregnancy weight gain and post partum weight retention Pregnancy link to Obesity? National Geographic 2004 Siega-Riz et al Nut Rev 62:S105-11

No exercise – Watching T.V. (sedentary lifestyle) Overweight/obesity; Body Mass Index – Weight/Height 2 (BMI>25; >30kg/m 2 ) GDM in previous pregnancy History of Large Babies > 9 lbs Family History of Diabetes Age Ethnicity – Aboriginal, Hispanic, South Asian, African Risk factors for GDM…..

Type 1 Later in life (type 2) Large babies at risk for obesity which is a risk factor for diabetes Vicious Circle!!! Offspring …..

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 Risk Factors for Childhood Obesity:

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 Influence on early post-natal life

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 Obesity prevention better than obesity treatment??

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?? Need Obesity prevention better than obesity treatment?? Title?

Prevention vs. treatment?? Intervention times? before conception during pregnancy early years of child’s life Impact of maternal & child health on current obesity epidemic

Causes: -input vs output -accelerated body weight gain -genetics; metabolic problems -excessive weight gain during pregnancy & weight retention -fetal programming? EATING HABITS ACTIVITY Awareness: Living in Balance

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 Programming evidence:

-Assumption of patterning -Stimulus at critical period of development has lasting effect 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 Oken & Gillman 2003; Catalano 2006 BMI Birth Weight Fetal Origins of Obesity:

BMI Birth Weight Mismatch - under-nutrition fetal environment - catch-up growth postpartum – rapid weight gain - abdominal obesity - large babies - large adults Birth weight/fat deposits

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

Birth Canal High Insulin Baby Low Blood Sugars High Sugars Overworked pancreas Fat Deposits At Birth

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 Rat Study (Bayol et al. 2007):

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) GDM

If we restore the balance, can obesity and diabetes be prevented in future generations?? Eating Habits Activity Rat Study (Bayol et al. 2007):

fruit cheese steak burrito pasta potato butter

’s

How can we make a difference in infancy? How can we make a difference during pregnancy??

SUPINE BLOOD FLOW MAY BE RESTRICTED STANDING NO RESTRICTION OF BLOOD FLOW INFERIOR VENA CAVA Position of Uterus against Inferior Vena Cava

NORMAL DIASTASIS RECTI

Correct Posture in standing position Keep the neck straight and the chin held up Lift up through the chest cage Keep the shoulders back; do not round shoulders forward Be careful of (posterior pelvic tilt) Bend the knees slightly Distribute the body weight on both feet NEUTRAL PELVIC ALIGNMENT

Daily activity before program: Pedometer Count: ±1794 Tudor-Locke & Bassett 2004 < 5000Sedentary Low Active Somewhat Active  10,000 Active >12,500Highly Active Steps/dayActivity Index

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 = 10,300 steps per day (end of program) Blood sugars monitored once per week – pre & post exercise with glucometer Davenport et al Appl Physiol Nutr Metab 33: Walking Program:

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 Walking effect on blood sugars?

EXERCISE PREGNANCY EVIDENCE-BASED GUIDELINES!!! RESEARCH QUESTIONS??

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: Activity - 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. Why should we promote health in the postpartum?

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 Summary of Preliminary Data

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. Guidelines

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 J. MidwiferyWomens Health 49:138-44)

? others ? Barriers to activity for new moms

Better understanding of women’s health promotion in the 1 st postpartum year is an essential step in addressing this neglect in maternal health. Barriers to activity for new moms

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

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: to download four page document Guidelines are the same for adult as for pregnant or postpartum woman: from Canada’s Physical Activity guide Guidelines form American College of Obstetricians and Gynecologists for exercise during postpartum period, 2003

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 Exercise in postpartum period

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 Activity & breastfeeding

Kegel exercises Pelvic tilts Shoulder rotations Half crunches Walking What feels right for new mom Important 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) Examples of post-natal muscle conditioning exercises

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 Returning to activity

We want to hear from you. Do you have any programs, resources to share? Add to our resource package. Programs and Learnings “from the field”

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? Group Work

Thank you for your attention and participation – we value your feedback! Evaluation time

- soon to be Louise Daw PARC Consultant PARC’s contact information: