Dr Karaponi Okesene-Gafa

Professor Lesley McCowan

Outline

Title- Nutrition and PA, back to the basics

Maternal Obesity

• Global, NZ, Local scene

• Impact on pregnancy outcomes

• Can we break the cycle?

• Evidence – interventions during pregnancy

• The HUMBA trial

• Other NZ Research

Global obesity epidemic the greatest human epidemic since 1990

NZ third most obese

in OECD

Best

Worst

Obese BMI >301 in 3 adults in NZ 1 in 4 in Australia

Global obesity - children

NZ third most obese

in OECD

Size of the problem in NZ :2013-14 Health Survey

30 % adults obese

Marked ↑ obesity in last 15 years

46% Maori adults obese

67% Pacific adults obese

One in three NZ children overweight / obese

44% Maori & 59% Pacific children overweight/ obese vs 28% European

No signs of epidemic abating

Costs of obesity in NZ exceed costs of cigarette smoking

BMI in pregnancy Counties 2014

Obese (BMI > 30) who birthed at CMH facility

• 65% of Pacific mothers

• 45% of Maori

• 26% of European

Counties Maternity Quality and Safety report 2014/2015

BMI of the women in CMH 2007 - 2009

Jackson report 2012

Relative Risk

Miscarriage 2

Preeclampsia 2-3

Gestational diabetes 3-4

Caesarean section 2

Pulmonary embolism 2

Postpartum haemorrhage 1.4

Infection 2.2

Maternal Complications with Obesity in Pregnancy

Women with GDM have a 50% risk of T2DM

(obstetricexcellence.com.au)

Gestational diabetes

http://chronicdiabetes.arccfn.org.au/47725/natural-ways-to-help-gestational-diabetes

Diabetes in pregnancy 1991-2008, National Women’s Health

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

GD

M

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Typ

e 1

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d 2

GDM Type I Type 2

Increased GDM in parallel with obesity epidemic

(Winnard 2012)

Diabetes in pregnancy CMH

Relative Risk

Congenital abnormality 2-3

Stillbirth 2-3

Neonatal Death 1.4

Large for gestational age 2.4

Shoulder dystocia 2.0

Reduced breastfeeding 0.7

Later obesity child/adulthood 2-3

Baby Complications with maternal obesity

Humanpath.com

Higher perinatal mortality in CMH

PMMRC 2015

Increased risk of stillbirthAuckland Stillbirth Study

-1.5

-1

-0.5

0

0.5

1

1.5

0 10 20 30 40 50 60 70

Body Mass Index

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lati

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just

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Dose dependent relationship

Stacey et al BMC pregnancy & childbirth 2011, 11:3

Obesity and breast feeding

Delayed onset, initiation and duration of breastfeeding

Mechanisms- not understood Hormonal?

? Related to Caesarean section

? Difficulty latching with breast size

? Other factors related to SES, ethnicity

Urgent need for research to understand mechanisms

Jevitt J Midwifery Womens Health 2007;52:606

What about pregnancy weight gain?

Institute of Medicine andNational Research Council, 2009 National Academy of Sciences

Pre-pregnancy BMI category

Total weight gain ( kg)

Underweight

(< 18.5 kg/m2)

12.5-18

Normal-weight

(18.5-24.9 kg/m2)

11.5-16

Overweight

(25.0-29.9 kg/m2)

7-11.5

Obese**

(≥ 30.0 kg/m2)

5-9

Caesarean section

Large for gestational age infants

Preeclampsia

Gestational diabetes

Postpartum weight retention

Long term obesity mum & baby

Excess pregnancy weight gain

Complications ≈ to booking BMI

Women with normal BMI -↑ risk with ↑weight gain

LGA

Preeclampsia

LSCS in labor Post-partum weight

Pregnancy complications & weight gain in pregnancy-

Rasmussen et al IOM guidelines 2009

Excessive pregnancy weight gain a modifiable risk factor?

Tongan mother Fourth baby Body mass index 32 At 36 weeks of pregnancy

has gained 26 kg Caesarean birth required due to

big baby Most women gain excess

weight in pregnancy!

Intergenerational cycle of obesity -diabetes

Excess fetalgrowth &

excess fat tissue

Newborn & childhood

obesity

Adult obesity +/-

type 2 diabetes

Abnormal metabolic environment in obese

pregnancy/GDM

http://chronicdiabetes.arccfn.org.au/47725/natural-ways-to-help-gestational-diabetes

Epigenetic effects

Pregnancy a teachable moment

Pregnant women more likely to undergo behavioural change if their baby will benefit

Pregnancy a finite period of time where change more likely to be maintained

Effective interventions potential to influence lifelong health for mother and baby

Interventions

Effect of diet & exercise

Dietary intervention & Outcome

Evidence of Interventions

Dietary Intervention & Baby Outcomes

Evidence – LIMIT trial

Adelaide (Australia)

1080 lifestyle intervention 1072 control

Large RCT pregnant women overweight/obese (25kg/m² and 30kg/m²)

Primary outcomes Secondary outcomes

Large for gestational age infants (LGA)

Infant

Maternal

Dietary intake & PA patterns

Psychological well being

Cost of healthcare

Dodd et al BMJ 10 Feb 2014;348:g1285 :g1285 doi: 10.1136/bmj.g1285

Evidence – LIMIT trial

Results

42% women exceeded - recommended pregnancy weight gain

No LGA infants (>90th percentile)Or pregnancy weight gain with intervention

There was no overall reduction in clinical outcomes

No impact on emotional well being

Dodd et al BMJ 10 Feb 2014;348:g1285 :g1285 doi: 10.1136/bmj.g1285

Evidence – LIMIT trial

Positive effects

Reduction Infant with weight >4kg - 0.56 (0.34 to 0.94)-18% babies >4kg

Women in lifestyle group increasedConsumption of fruits and vegesFibre content % of energy from saturated fats

physical activity360 MET units per week(15-20mins of brisk walking most days)

(Dodd et al. BMC Medicine 2014, 12:163)

Evidence – UPBEAT trial

UPBEAT – the UK pregnancies better eating and activity trial

Women BMI >30 kg/m²8 hospitals Inner City UKMulti-ethnic populations> 16 years15-18 weeks gestation

Behavioural interventionN = 783

Standard antenatal care772

ResultsThere were no differences in the main outcomes

Outcomes Groups N (%)

Gestational diabetesRR 0.96 (95% CI 0.79-1.16, p 0.68)

Standard care 172 (26)

Intervention 160 (25)

LGA babies (>90th %ile customised)Standard care 61 (8)

Intervention 71 (9)

However – women in the intervention group - Increased their PAReduced- dietary glycaemic load, gestational weight gain, and skin fold thickness

Microbiome & ObesityNZ Herald Sat 7 September 2013

Gut microbiome- many roles in health

Energy balance, provision of micronutients & fatty acids

Immune defenses

Composition differs in obese vs non-obese

Modification of microbiome may improve metabolic health

Evidence - interventions

Probiotics modify the gut microbiome

“Live micro-organisms – when ingested in adequate amounts confer health benefit to the host” [FAO 2001]

Act – several ways

- antibacterial activity

- modulate systemic immune

- pathogen exclusion (bind to R sites) Probiotics

RCT Probiotics (Finnish Trial)

Mothers 256

Diet education +Probiotics

Diet +Placebo

Control

Total 191 followed up in 24 months

General obstetric populationMarked ↓ GDM

GDM = 13% GDM = 36% GDM = 32%

(Luoto etal)

(Current = SPRING Trial in Australia RCT in 600 overweight/obese pregnant women)

Text Messaging

Positive results with weight loss in non pregnant population

Beneficial effect with smoking cessation

Can be incorporated into clinical care

Incorporated in HUMBA dietary intervention

“Remember to only eat for you and not for two”

Current research - HUMBA

Background to HUMBA

External review of maternity care in CMH in 2012 noted the high perinatal mortality and the association with obesity

It recommended that:

Our Research Journey

• Improved Health for me and my Baby

• Providing Childcare

• Allowing other family members to participate

• Programme in my own language

CompletedCompleted Completed Current

Nutrition Survey Results

N = 422

Maternal Age Gestation Nulliparous ≥ 1 child

29 years 29 weeks 20% 80%

September – December 2013

Results - BMI of Women

BMI during survey (%)

Total Maori

N=102

Pacific

N=171

Asian/OtherN=54

European

N=92

BMI <25 24% 12% 8% 61% 46%

Overweight BMI25-29.9 27% 25% 25% 30% 32%

Obesity >=30 47% 63% 66% 7% 16%

Results - Knowledge

Knew about healthy eating? 99%

Received info – healthy eating? 95%

Most trusted source (Multiple answers)

Midwife 82%

GP 40%

Family/whanau 17%

Friends 5%

Self reported healthy eating

Self reported Healthy Eating

Total

(%)

Maori

N=102

Pacific

N=171

Asian/OtherN=54

European

N=92

VeryFrequent 26% 4% 12% 63% 55%

Frequent 35% 37% 34% 33% 35%

Occasional 36% 55% 49% 4% 10%

Rare/Never 3% 4% 5% 0 0

No Eating more Eating less

47% 44% 9%

Results – Eating habits

N=422

Changed?

N = 187 eating more

Cravings Eating for 2 Culture/Belief Family recom Nausea/V

70% 63% 32% 32% 17%

Participation future program

Participate N (%)

Very Likely 221 (52)

Likely 131 (31)

Most important reasonImproved health of mum

and baby (81%)

Access %

Mobile 98

Internet 93

Ipad 88

One to one n=292(69%)

c.f. Group n = 131(30%)

Preferred settings

Preferred location N (%)

Clinic 53 (41%)

Community Hall 40 (31%)

Most suitable day Never

Weekday Weekend

Thank you everyone who assisted with the survey

Our Journey to HUMBA

completed completed

HUMBA pilot

Outcomes

Excess GWGFetal weight

completed

HUMBA Main Objectives

To determine if dietary education and/or probiotics:

Reduce excessive pregnancy weight gain & improve glucose metabolism

Optimise infant birth weight

Reduce maternal and infant adiposity 4-6 months after birth

x

Eligibility: 12-17 weeks of pregnancy BMI ≥ 30 Single baby No diabetes Not on probiotics Written informed consent

Randomised to: dietary education including text messages or routine dietary

advice and probiotics or placebo (N=220)

Who can take part in HUMBA?

Routine dietary advice group

Receive the MoH information on:

Eating for Healthy Pregnant Women

AND

Healthy Weight gain in Pregnancy leaflet

Probiotics / placebo

No text messages

4 education sessions:• Brief dietary and physical activity assessment

• Educating women (+/- family) regarding healthy diet and physical activity

• Helping women set 3 SMARTER goals at each visit

Text messages x3/week

Probiotics/Placebo

Intervention arm

Remember mum, whatever you eat I also eat –please choose carefully

Women in the intervention group:

• Limit gestational weight gain 5-9kg

• Improve dietary intake (reducing fat, sugar increasing fibre, portion control)

• Improve levels of physical activity

Aims

Diet intervention group - CHWs

CHWs Trained Certificate in Pacific Nutrition (AUT &National Heart Foundation)

Healthy conversations(Gravida)

Oversight – qualified dietitan

Handbook for mumswith recipes

• Weight gain in pregnancy

• Aims of HUMBA

• How to limit gestational weight gain

• Additional nutrition issues

• Myths / cultural beliefs around food and exercise for weight

loss & in pregnancy

HUMBA handbook for mum

1. Types of foods and drinks:Eat plenty “everyday” foodsLimit intake of “sometimes” foods - foods and drinks high in sugar and/or fat

2. Meal pattern:Aim for 3 meals per dayHealthy small snacks in-between meals

3. Portion control:Healthy plate model

Eating for 2 is not necessary!

4. Managing food cravings

5. Keeping physically active

Limiting pregnancy weight gain

8 teaspoons sugar1 tsp

sugarNo Sugar, No Carbohydrate, No Calories

Aim for 3 meals per day

• Common for people to skip meals, particularly breakfast (or first meal in the day)

• Aim for 4-5 hour gap between each meal– Doesn’t matter what time start eating in the day – sleep in/shift workers

• Aim to eat some carbohydrate food(s) at each meal

Meal pattern

Healthy snacks

• Can include a small healthy snacks in-between meals.

• Swapping snacks

Meal pattern

• Pre-HUMBA survey:

– Second most common reason for eating more I

“I’m eating for two”.

• Emphasize not eating for 2!

• Obese pregnant woman only need a small amount of extra food

– Equivalent: 2 small apples or 1 slice of bread per day

Portion control

Healthy Plate Model

Portion control

Fist sizePalm size

Half the plate

Pre-HUMBA survey: Cravings was the number one reason why pregnant women ate more.

Reassure women normal part of pregnancy

Cause: ?Hormonal changes

Doesn’t mean our body or baby is lacking in a certain nutrient

Cravings (head hunger)

Physical hunger (from neck tostomach)

Head hunger (from neck up)

Stomach rumbling, lightheaded, grumpy, tired

Our brain telling us we are not (or are) happy about something. E.g bored, stressed, sad, happy, social, relaxing

Builds up over time Comes on quickly

Occurs around meal times Can be anytime of the day

Goes away after eating Doesn’t go away after eating

Eating leads to a feeling of satisfaction

Eating may lead to guilt and shame

Physical vs head hunger

• If the craving hasn’t passed

– can you replace it with a healthier option?

Cravings cont…

• Research tells us that dietary based programmes are the most effective in reducing gestational weight gain.

• Try to call it physical activity / movement rather than ‘exercise’.

• HUMBA aim: 30 minutes 3 times a week

– Can break it into smaller 10 minute sessions

Physical activity

Visit 1: Increasing everyday physical activity

Visit 2: Keeping active throughout the day

Visit 4: Keeping active through leisure activities

Physical activity themes

Others

• Reduce takeaways

• How to read food labels

• Meal planning

• Setting SMARTER goals

Dietary Intervention in HUMBA

Summary

• 4 visits with Community Health Worker - goal setting!

• Portion size, not eating for two, healthy weight gain

• vegetables and fruit

• Managing cravings/mindfulness

• drink water and low fat milk not SSBs

• home cooked meals, healthy recipes & takeaways

• Label reading

• Increase physical activity- walking

• Motivational texts 3 X /week -reinforce education

HUMBARCT

N = 220

LIPIDS entry 28 ,

36 wks and 5mths post

birth

HBA1c entry 28 ,

36 wks and 5mths post

birth

Urine & blood at entry & 36wks

Mother & offspring stool for

Microbiome

Maternal Follow up

studies

Childhood Follow up

studies

SCIENCE ALL PARTICIPANTS

SCIENCE CASE CONTROL

CHILDREN FOLLOW-UP

MATERNAL FOLLOW-UP

Research collaborations with HUMBA

Biobank

Breast feeding studies

Hair sample at 36 weeksmetabolome

Infancy & childhood

body composition

• 47 recruited- recruitment slower than anticipated– Maori 14.8%

– Pacific Island 60.4%

– European 23.5%

– Indian 4.9%

– Asian 1.2%

– Other 2.5%

Will assess feasibility and success of our interventions in a high needs community

Community Health Worker as a dietary educator will be evaluated

Could be incorporated into models of care in pregnancy and elsewhere if successful

Progress to date

How you can help?Keep a log of names & contact details & let us know by:

• Telephone: HUMBA 027 486 2200Cecile O’Driscoll 021 811 211Sarah Va'afusuaga 021 82 4071• Email: humba@auckland.ac.nz• Fax HUMBA: 09 263 1385

• Like our facebook pagehttp://www.facebook.com/humba.nz

• Visit our websitehttp://www.humba.ac.nz/

• Give out hand outs

AdvertisingPlease

Ask women you know/in your care– interested in participating

Give them a pamphlet

Acknowledgements - funders

Cure Kids

Lottery Research Grant

Mercia Barnes Trust

University of Auckland

Counties Manukau Health

Acknowledgements- funders & supporters

National Heart Foundation -

training of Community Health Workers

In kind support

Christian Hansen- probiotics

Roche International- equipment & consumables for HBA1c

New Zealand ColleMidwifery Council

CPD points recruitment to HUMBA

NIHI

Acknowledgement - support

Research team

Midwives - LMCs, Community midwives, DHB, etc

GPs/Practice nurses

TAHA (Well Pacific Mother and Infant service)

Pacific Heart Beat (National Heart Foundation)

Pacific and Maori Health Team CMH

The IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) Trial

Trial of stationary cycling from 20-36 weeks’ Overweight and obese women (n=75) Improved fitness but only 30% compliance with exercise

regime No improvement in :

Pregnancy weight gain Pregnancy outcomes Infant birthweight Maternal body composition

Not a solution at population level

The NiPPeR Trial

Pre-pregnancy nutritional intervention Women planning to be pregnant (n=600 from Auckland) Receive a sachet with multiple micronutrients, probiotics

and myoinositol or placebo (standard pregnancy nutrients) -prior to pregnancy and continued until birth

Aim to determine whether pre-pregnany intervention that is continued during pregnancy improves maternal glucose metabolism and baby health

Recruitment due to start soon Limitation- those with most to benefit less likely to plan

pregnancy

Conclusion

There is a worldwide epidemic of obesity

High prevalence of obesity in CMH populations

Interventions in pregnancy – shown to improve outcomes

We are trialling these in Counties (hoping to recruit a

Significant number of Pacific women)

Grateful to the funders and everyone assisting –recruitment

This study – requires a lot of collaboration

Kia ora, Malo aupito, Faafetai, Meitaki maata

Fakaue lahi and Thank you