1. Dietary interventions in Obese Pregnancy: An Australian study and systematic review of the literature Professor Julie Quinlivan

2. 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.

3. 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.

4. 2. Increasing weight gain in pregnancy 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. PeriodMean weight gain in pregnancy 1960-19708.5-10kg 1980-19909-11kg 1990-200010-14kg 2000-201013-15kg

5. 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

6. 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.

7. What is the impact of maternal BMI on GDM? 25-3031-4040+ Rate of GDM 2-5%7-12%17-25% Example: GDM

8. The obesity epidemic and an increase in pregnancy weight gain have increased gestational diabetes.....

9. .....and then, along comes evidence that we have been under diagnosing gestational diabetes to the detriment of women and their babies.

10. H yperglycaemia and A dverse P regnancy O utcomes 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. HAPO

11. 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. The Randomised trials

12. Birth weight >90 th centile Cord blood C-peptide >90 th 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 Significant improvements

13. 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) Post HAPO

14. 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.

15. 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.

16. 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

17. Options * Exercise X * Psychological X * Diet ????

18. 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.

19. Triangle of intervention HIGH LOW

20. 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

21. 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.

22. 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.

23. 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

24. VariablesInterventionControlP-value GDM (%)6290.04 Weight gain (kg) 7.0 (0.65)13.8 (0.67)<0.001 Birthweight3.5 (0.07)3.4 (0.10)0.162 Outcome data

25. VariablesInterventionControlP-value GDM (%)6290.04 Weight gain (kg) 7.0 (0.65)13.8 (0.67)<0.001 Birthweight3.5 (0.07)3.4 (0.10)0.162 Outcome data IOL : Obese women 4.9 to 9kg

26. Variables (N)First visit (N=63) Final visit (N=63) Fizzy drinks6123 Water247 Fast food4021 Home cooked meal2342 Fresh fruit542 Fresh vegetable1142 Diet changes

27. 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.

28. What do other RCT in the literature show? Is there a pattern? Can we develop an even simpler intervention that works?

29. 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

30. 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

31. 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

32. Guelinckx et al. (2010) Belgium 1. Continuity of care 2. Single visit by a dietician. SINGLE INTERVENTION NOT EFFECTIVE

33. Quinlivan et al, 2011 Australia REPEATED INTERVENTION EFFECTIVE

34. Meta analysis – Impact upon maternal weight gain

36. 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.

37. 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.

38. Enrole: Women presenting 25 Intervention 3 step model versus existing model of care 1 0 Outcomes: * Reduce gestational weight gain * Reduce gestational diabetes (15% to 10%) Sample size: N=1450 The Diary RCT

39. 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.

40. 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

41. Thankyou