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Note: for non-commercial purposes only Maternal Nutrition and Fetal Health intervention studies in Pregnancy ROLO and PRoPS Prof Fionnuala McAuliffe University College Dublin National Maternity Hospital Background Childhood obesity

  1. Note: for non-commercial purposes only Maternal Nutrition and Fetal Health – intervention studies in Pregnancy ‘ROLO and PRoPS’ Prof Fionnuala McAuliffe University College Dublin National Maternity Hospital

  2. Background Childhood obesity

  3. Obesity in Pregnancy

  5. Maternal Obesity - maternal risk

  6. Fetal problems Walsh, McAuliffe 2012

  7. The westernised diet rich in carbohydrates is thought to contribute to the rates of obesity

  8. Background • Glucose is the main energy substrate for intrauterine growth Clapp JF 2002, McGowan, McAuliffe BJN 2010

  9. Background • Glucose is the main energy substrate for intrauterine growth Clapp JF 2002, McGowan, McAuliffe BJN 2010 • Maternal glucose concentrations below those diagnostic of diabetes associated with increased birthweight and adverse outcomes HAPO 2008

  10. Background • Maternal diet, particularly its carbohydrate type and content, influences maternal blood glucose concentrations Clapp JF 2002, McGowan, McAuliffe BJN 2010

  11. Not all carbohydrate foods are created equal High GI Medium GI Low GI

  12. Not all carbohydrate foods are created equal High GI Medium GI Low GI

  13. Not all carbohydrate foods are created equal High GI Medium GI Low GI

  14. Not all carbohydrate foods are created equal High GI Medium GI Low GI

  15. Glycemic Index • The incremental area under the blood glucose curve after ingestion of 50 grams of a test food Jenkins 1981

  16. Glycemic Index • The incremental area under the blood glucose curve after ingestion of 50 grams of a test food Incremental blood glucose concentration Jenkins 1981 Time (minutes)

  17. Background • Pregnancy is a condition in which the glycaemic index may be of particular relevance Fraser 1988

  18. Hypothesis • A low glycemic index diet in pregnancy could prevent recurrence of fetal macrosomia Walsh J, Mahony R, Foley M, McAuliffe F. BMC Pregnancy Childbirth 2010

  19. RCT Of LOw glycaemic index diet vs usual diet to prevent macrosomia ROLO study Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  20. ROLO • Randomized control trial n=800 • Inclusion criteria: – Secundigravid – Previous birthweight >4000g • Exclusion criteria: – Previous gestational diabetes Walsh J, Mahony R, Foley M, McAuliffe F. Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  21. ROLO - Objectives • Primary outcome: Birthweight • Secondary outcome: Gestational weight gain Walsh J, Mahony R, Foley M, McAuliffe F. Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012 BMC Pregnancy Childbirth 2010

  22. ROLO • Recruited and randomized at first antenatal consultation Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  23. ROLO Control Arm: • Routine antenatal care • No formal dietary advice • No advice on weight gain in pregnancy Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  24. ROLO Intervention arm: • Dietary education session: re-enforcement during pregnancy • Small groups of 2 – 6 people • Lasted 2 hours • Gestation 15.7+/-3.0 weeks Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  25. Dietary Intervention • Women were first given advice on healthy eating guidelines for pregnancy

  26. Dietary Intervention • Focused on the glycemic index • Exchange high GI carbohydrates for low GI alternatives • Written information and low GI recipes • No advice on gestational weight gain Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  27. Results – Glycaemic Load Intervention Group Control Group Low GI diet 132 ± 33 136 ± 38 Early pregnancy 124 ± 32 140 ± 32* Second trimester 127 ± 30 140 ± 37 * Third trimester Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  28. Results – Glycaemic Load Intervention Group Control Group Low GI diet 132 ± 33 136 ± 38 Early pregnancy 124 ± 32 140 ± 32* Second trimester 127 ± 30 140 ± 37 * Third trimester Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  29. Results – Glycaemic Load Intervention Group Control Group Low GI diet 132 ± 33 136 ± 38 Early pregnancy 124 ± 32 140 ± 32* Second trimester 127 ± 30 140 ± 37 * Third trimester Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  30. Results – Glycaemic Load Intervention Group Control Group Low GI diet 132 ± 33 136 ± 38 Early pregnancy 124 ± 32 140 ± 32* Second trimester 127 ± 30 140 ± 37* Third trimester Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  31. Results – Primary Outcome

  32. Intervention Group Control Primary outcome - Birthweight Low GI diet Group 4034 ± 510 4006 ± 497 Birthweight (grams) 70.5 ± 25.6 72.8 ± 25.6 Birthweight centile 52.9 ± 2.7 52.6 ± 2.1 Length at birth (cm) 35.8 ± 1.3 35.7 ± 1.5 Head circumference at birth (cm) Ponderal Index at birth (Kg/cm3) 2.76+/-3.8 2.75+/-0.33 -214.2 ± 541 -250.8 ± 512 Birthweight difference (grams) Fetal macrosomia (>4000g) 50.7% 51.5%

  33. Results – Secondary Outcome

  34. Intervention Group Control Group Results – Gestational weight gain Low GI diet 5.3 ± 2.7 5.5 ± 2.7 Weight gain at 24 weeks (kg) 7.1 ± 2.8 7.7 ± 3.0 * Weight gain at 28 weeks (kg) 10.1 ± 3.7 10.9 ± 3.9* Weight gain at 34 weeks (kg) 12.2 ± 4.4 13.7 ± 4.9 * Weight gain at 40 weeks (kg) Exceeded IOM gestational 37.7% 47.9% * weight gain guidelines (%)

  35. Intervention Group Control Group Results – Gestational weight gain Low GI diet 5.3 ± 2.7 5.5 ± 2.7 Weight gain at 24 weeks (kg) 7.1 ± 2.8 7.7 ± 3.0 * Weight gain at 28 weeks (kg) 10.1 ± 3.7 10.9 ± 3.9* Weight gain at 34 weeks (kg) 12.2 ± 4.4 13.7 ± 4.9 * Weight gain at 40 weeks (kg) Exceeded IOM gestational 37.7% 47.9% * weight gain guidelines (%)

  36. Intervention Group Control Group Results – Gestational weight gain Low GI diet 5.3 ± 2.7 5.5 ± 2.7 Weight gain at 24 weeks (kg) 7.1 ± 2.8 7.7 ± 3.0 * Weight gain at 28 weeks (kg) 10.1 ± 3.7 10.9 ± 3.9* Weight gain at 34 weeks (kg) 12.2 ± 4.4 13.7 ± 4.9 * Weight gain at 40 weeks (kg) Exceeded IOM gestational 37.7% 47.9% * weight gain guidelines (%)

  37. Results – Maternal glucose

  38. Intervention Group Control Group Low GI diet 28 week fasting 24 / 321 41/352 glucose >5.1mmol/L (7.5%) (11.6%) 54/350 79/371 * GCT >7.8 (15.4%) (21.3%)* 28 week fasting 67/320 100/352 glucose >5.1mmol/L or (20.9%) (28.4%) * GCT>7.8mmol/L 42/350 52/371 GCT >8.3mmol/L (12%) (14%) Gestational diabetes 7/350 9/371 Carpenter and Coustan (2%) (2.4%) criteria Gestational diabetes 12/350 18/371 American Diabetes (3.4%) (4.9%) Association criteria

  39. Intervention Group Control Group Low GI diet 28 week fasting 24 / 321 41/352 glucose >5.1mmol/L (7.5%) (11.6%) 54/350 79/371 * GCT >7.8 (15.4%) (21.3%)* 28 week fasting 67/320 100/352 glucose >5.1mmol/L or (20.9%) (28.4%) * GCT>7.8mmol/L 42/350 52/371 GCT >8.3mmol/L (12%) (14%) Gestational diabetes 7/350 9/371 Carpenter and Coustan (2%) (2.4%) criteria Gestational diabetes 12/350 18/371 American Diabetes (3.4%) (4.9%) Association criteria

  40. Intervention Group Control Group Low GI diet 28 week fasting 24 / 321 41/352 glucose >5.1mmol/L (7.5%) (11.6%) 54/350 79/371 * GCT >7.8 (15.4%) (21.3%)* 28 week fasting 67/320 100/352 glucose >5.1mmol/L or (20.9%) (28.4%) * GCT>7.8mmol/L 42/350 52/371 GCT >8.3mmol/L (12%) (14%) Gestational diabetes 7/350 9/371 Carpenter and Coustan (2%) (2.4%) criteria Gestational diabetes 12/350 18/371 American Diabetes (3.4%) (4.9%) Association criteria

  41. Results - Compliance Compliance Scale % Followed the diet ‘ all of the 3.8 time ’ Followed the diet ‘ most of the 76.4 time ’ Followed the diet ‘ some of 17.0 the time ’ Followed the diet ‘ none of the 2.8 time ’ Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  42. Results - Compliance Compliance Scale % Followed the diet ‘ all of the 3.8 time ’ Followed the diet ‘ most of the 76.4 time ’ Followed the diet ‘ some of 17.0 the time ’ Followed the diet ‘ none of the 2.8 time ’ Walsh, McGowan, Mahony, Foley, McAuliffe BMJ 2012

  43. Maternal Nutrient Intakes Trimester 1 Trimester 2 Trimester 3 Int Control Int Control Int Control Energy (MJ) Protein (%TE) CHO (% TE) Fibre (g) P value – independent samples t test McGowan, McAuliffe J Nut 2014

  44. Maternal Nutrient Intakes Trimester 1 Trimester 2 Trimester 3 Int Control Int Control Int Control Energy (MJ) 7.7 7.8 7.6 8.1** 7.6 8.1* Protein (%TE) 17.2 16.8 17.8 16.8*** 17.6 16.7** CHO (% TE) 50.3 50.3 49.0 50.0 49.1 50.1 Fibre (g) 19.9 18.9 20.2 19.2 20.3 18.8** P value – independent samples t test McGowan, McAuliffe J Nut 2014

  45. Maternal Nutrient Intakes Trimester 1 Trimester 2 Trimester 3 Int Control Int Control Int Control Energy 7.6 8.1** 7.6 8.1* 7.7 7.8 Protein (%TE) 17.2 16.8 17.8 16.8*** 17.6 16.7** CHO (% TE) 50.3 50.3 49.0 50.0 49.1 50.1 Fibre (g) 19.9 18.9 20.2 19.2 20.3 18.8** P value – independent samples t test McGowan, McAuliffe J Nut 2014

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