Postpartum diet quality in Australian women following a gestational diabetes pregnancy

BACKGROUND/OBJECTIVES: To describe the diet quality of a national sample of Australian women with a recent history of gestational diabetes mellitus (GDM) and determine factors associated with adherence to national dietary recommendations. SUBJECTS/METHODS: A postpartum lifestyle survey with 1499 Australian women diagnosed with GDM p3 years previously. Diet quality was measured using the Australian recommended food score (ARFS) and weighted by demographic and diabetes management characteristics. Multinominal logistic regression analysis was used to determine the association between diet quality and demographic characteristics, health seeking behaviours and diabetes-related risk factors. RESULTS: Mean (±s.d.) ARFS was 30.9±8.1 from a possible maximum score of 74. Subscale component scores demonstrated that the nuts/legumes, grains and fruits were the most poorly scored. Factors associated with being in the highest compared with the lowest ARFS quintile included age (odds ratio (OR) 5-year increase=1.40; 95% (confidence interval) CI:1.16–1.68), tertiary education (OR=2.19; 95% CI:1.52–3.17), speaking only English (OR=1.92; 95% CI:1.19–3.08), being sufficiently physically active (OR=2.11; 95% CI:1.46–3.05), returning for postpartum blood glucose testing (OR=1.75; 95% CI:1.23–2.50) and receiving riskreduction advice from a health professional (OR=1.80; 95% CI:1.24–2.60). CONCLUSIONS: Despite an increased risk of type 2 diabetes, women in this study had an overall poor diet quality as measured by the ARFS. Women with GDM should be targeted for interventions aimed at achieving a postpartum diet consistent with the guidelines for chronic disease prevention. Encouraging women to return for follow-up and providing risk reduction advice may be positive initial steps to improve diet quality, but additional strategies need to be identified.

Pilot study of an individualised early post partum intervention to increase physical activity in women with previous gestational diabetes

Background: Whilst the benefits of physical activity in preventing progression from impaired glucose tolerance to overt diabetes in older adults are well recognised, it is not clear which strategies may prevent progression to overt diabetes in women with recent gestational diabetes. We sought to devise and pilot test a convenient, home based exercise program with telephone support, suited to the early post partum period. Twenty eight women with recent gestational diabetes were enrolled six weeks post partum into a 12 week randomised controlled trial of Usual Care ("UC" Controls (n= 13)) vs. Supported Care ("SC" individualised exercise program with regular telephone support (n= 15)). Findings: Baseline characteristics for the whole cohort at six weeks post partum (Mean ± SD) were Age 33 ± 4 years, Weight 80 ± 20 kg and Body Mass Index (BMI) 30.0 ± 9.7 kg / m2. The primary outcome, planned physical activity, increased by Median (Range) 60 (0-540) mins/wk in the SC group vs. 0 (0-580) mins/wk in the UC group (p = 0.234, Mann Whitney U test). The change in planned physical activity predominantly comprised planned walking. Body weight, BMI, waist circumference, % body fat (measured by bioimpedance), fasting glucose and insulin did not change significantly over time in either group. Conclusions: The intervention designed to increase physical activity in post partum women with previous gestational diabetes was feasible. However, no evidence to suggest that this type of program provides any measurable improvement in metabolic or biometric parameters over a three month post partum follow up was observed.

Gestational Diabetes Mellitus in Far North Queensland, Australia, 2004 to 2010 : midwives’ perinatal data most accurate source

Objectives: This study examines the accuracy of Gestational Diabetes Mellitus (GDM) case-ascertainment in routinely collected data. Methods: Retrospective cohort study analysed routinely collected data from all births at Cairns Base Hospital, Australia, from 1 January 2004 to 31 December 2010 in the Cairns Base Hospital Clinical Coding system (CBHCC) and the Queensland Perinatal Data Collection (QPDC). GDM case ascertainment in the National Diabetes Services Scheme (NDSS) and Cairns Diabetes Centre (CDC) data were compared. Results: From 2004 to 2010, the specificity of GDM case-ascertainment in the QPDC was 99%. In 2010, only 2 of 225 additional cases were identified from the CDC and CBHCC, suggesting QPDC sensitivity is also over 99%. In comparison, the sensitivity of the CBHCC data was 80% during 2004–2010. The sensitivity of CDC data was 74% in 2010. During 2010, 223 births were coded as GDM in the QPDC, and the NDSS registered 247 women with GDM from the same postcodes, suggesting reasonable uptake on the NDSS register. However, the proportion of Aboriginal and Torres Strait Islander women was lower than expected. Conclusion: The accuracy of GDM case ascertainment in the QPDC appears high, with lower accuracy in routinely collected hospital and local health service data. This limits capacity of local data for planning and evaluation, and developing structured systems to improve post-pregnancy care, and may underestimate resources required. Implications: Data linkage should be considered to improve accuracy of routinely collected local health service data. The accuracy of the NDSS for Aboriginal and Torres Strait Islander women requires further evaluation.

Postpartum care for Aboriginal and non-Aboriginal women with Gestational Diabetes Mellitus across urban, rural and remote locations : a protocol for a cohort linkage study

Background: Gestational diabetes mellitus (GDM) is increasing, along with obesity and type 2 diabetes (T2DM), with Aboriginal and Torres Strait Islander people* in Australia particularly affected. GDM causes serious complications in pregnancy, birth, and the longer term, for both women and their infants. Women diagnosed with GDM have an eightfold risk of developing T2DM after pregnancy, compared with women who have not had GDM. Indigenous women have an even higher risk, at a younger age, and progress more quickly from GDM to T2DM, compared to non-Indigenous women. If left undetected and untreated, T2DM can lead to heart disease, stroke, renal disease, kidney failure, amputations and blindness. A GDM diagnosis offers a ‘window of opportunity’ for diabetes health interventions and it is vital that acceptable and effective prevention, treatment, and post-pregnancy care are provided. Low rates of post-pregnancy screening for T2DM are reported among non-Aboriginal women in Australia and among Indigenous women in other countries, however data for Aboriginal women are scarce. Breastfeeding, a healthy diet, and exercise can also help to prevent T2DM, and together with T2DM screening are recommended elements of ‘post-pregnancy care’ for women with GDM, This paper describes methods for a data linkage study to investigate rates of post-pregnancy care among women with GDM. Methods/Design: This retrospective cohort includes all women who gave birth at Cairns Base Hospital in Far North Queensland, Australia, from 2004 to 2010, coded as having GDM in the Cairns Base Hospital Clinical Coding system. Data linkage is being conducted with the Queensland Perinatal Data Collection, and three laboratories. Hospital medical records are being reviewed to validate the accuracy of GDM case ascertainment, and gather information on breastfeeding and provision of dietary advice. Multiple logistic regression is being used to compare post-pregnancy care between Aboriginal and non-Aboriginal women, while adjusting for other factors may impact on post-pregnancy care. Survival analysis is being used to estimate the rates of progression from GDM to T2DM. Discussion: There are challenges to collecting post-pregnancy data for women with GDM. However, research is urgently needed to ensure adequate post-pregnancy care is provided for women with GDM in Australia.

Growth patterns in preterm infants born appropriate for gestational age

Aim: This study aimed to document the growth patterns of a contemporary cohort of preterm infants born appropriate for gestational age (AGA). It was hypothesised that preterm AGA (PT-AGA) infants would display poorer growth than full-term AGA (FT-AGA) infants. Methods: Sixty-four PT-AGA infants and 64 FT-AGA infants were assessed at 0, 4, 8 and 12 months of corrected age (CA). Measurements of weight and length were recorded at each of the specified ages. Centers for Disease Control and Prevention growth data were used to calculate Z-scores for weight and length based on CA. Results: The mean length and weight Z-scores of PT-AGA infants were found to be significantly less than those of FT-AGA infants at term, 4, 8 and 12 months of CA (P < 0.001). The mean weight Z-score of PT-AGA infants was found to be less than their mean length Z-score at each time point, though the differences were not significant. Conclusions: The results of this study suggest that PT-AGA infants are likely to display poorer growth than FT-AGA infants until at least 1 year of CA. Long-term growth monitoring in this population is recommended. © 2008 The Authors.

Associations with low rates of postpartum glucose screening after gestational diabetes among Indigenous and non-Indigenous Australian women

OBJECTIVES To explore factors associated with postpartum glucose screening among women with Gestational Diabetes Mellitus (GDM). METHODS A retrospective study using linked records from women with GDM who gave birth at Cairns Hospital in Far North Queensland, Australia, from 1 January 2004 to 31 December 2010. RESULTS The rates of postpartum Oral Glucose Tolerance Test (OGTT) screening, while having increased significantly among both Indigenous* and non-Indigenous women from 2004 to 2010 (HR 1.15 per year, 95%CI 1.08-1.22, p<0.0001), remain low, particularly among Indigenous women (10% versus 27%, respectively at six months postpartum). Indigenous women in Cairns had a longer time to postpartum OGTT than Indigenous women in remote areas (HR 0.58, 0.38-0.71, p=0.01). Non-Indigenous women had a longer time to postpartum OGTT if they: were born in Australia (HR 0.76, 0.59-1.00, 0.05); were aged <25 years (HR 0.45, 0.23-0.89, p=0.02); had parity >5 (HR 0.33, 0.12-0.90, p=0.03); smoked (HR 0.48, 0.31-0.76, p=0.001); and did not breastfeed (HR 0.09, 0.01-0.64, p=0.02). CONCLUSIONS Postpartum diabetes screening rates following GDM in Far North Queensland are low, particularly among Indigenous women, with lower rates seen in the regional centre; and among non-Indigenous women with indicators of low socioeconomic status. IMPLICATIONS Strategies are urgently needed to improve postpartum diabetes screening after GDM that reach women most at risk.

Changes in resting and walking energy expenditure and walking speed during pregnancy in obese women

Background Energy conserving processes reported in undernourished women during pregnancy are a recognised strategy to provide energy required to support fetal development. Women who are obese before conceiving arguably have sufficient fat stores to support the energy demands of pregnancy without the need to provoke energy conserving mechanisms. Objective We tested the hypothesis that obese women would demonstrate behavioural adaptation (i.e. decrease in self-selected walking (SSW) speed) but not metabolic compensation (i.e. decrease in resting metabolic rate (RMR) or metabolic cost of walking) during gestation. Design RMR, SSW speed, metabolic cost of walking, and anthropometry were measured in 23 women (BMI: 33.6 ± 2.5 kg/m2; 31 ± 4 years) at approximately weeks 15 (wk 15) and 30 (wk 30) of gestation. RMR was also measured in two cohorts of non-pregnant controls matched for age, weight and height of the pregnant cohort at wk 15 (N=23) and wk 30 (N=23). Results GWG varied widely (11.3 ± 5.4 kg) and 52% of women gained more weight than is recommended. RMR increased significantly by an average 177 ± 176 kcal/d (11±12%; P<0.0001); however the within-group variability was large. Both the metabolic cost of walking and SSW speed decreased significantly (P<0.01). While RMR increased in >80% of the cohort, the net oxygen cost of walking decreased in the same proportion of women. Conclusions While the increase in RMR was greater than was explained by weight gain, there was evidence of both behavioural and biological compensation in the metabolic cost of walking in obese women during gestation.

Maternal exposure to ambient temperature and the risk of preterm birth and stillbirth in Brisbane, Australia

Almost 10% of all births are preterm and 2.2% are stillbirths globally. Recent research has suggested that environmental factors may be a contributory cause to these adverse birth outcomes. The authors examined the relationship between ambient temperature and preterm birth and stillbirth in Brisbane, Australia between 2005 and 2009 (n = 101,870). They used a Cox proportional hazard model with live birth and stillbirth as competing risks. They also examined if there were periods of the pregnancy where exposure to high temperatures had a greater effect. Exposure to higher ambient temperatures during pregnancy increased the risk of stillbirth. The hazard ratio for stillbirth was 0.3 at 12 °C relative to the reference temperature at 21 °C. The temperature effect was greatest for fetuses of less than 36 weeks of gestation. There was an association between higher temperature and shorter gestation, as the hazard ratio for live birth was 0.96 at 15 °C and 1.02 at 25 °C. This effect was greatest at later gestational ages. The results provide strong evidence of an association between increased temperature and increased risk of stillbirth and shorter gestations.

The influence of ambient temperature on birth outcomes in Brisbane, Australia

Lately, there has been increasing interest in the association between temperature and adverse birth outcomes including preterm birth (PTB) and stillbirth. PTB is a major predictor of many diseases later in life, and stillbirth is a devastating event for parents and families. The aim of this study was to assess the seasonal pattern of adverse birth outcomes, and to examine possible associations of maternal exposure to temperature with PTB and stillbirth. We also aimed to identify if there were any periods of the pregnancy where exposure to temperature was particularly harmful. A retrospective cohort study design was used and we retrieved individual birth records from the Queensland Health Perinatal Data Collection Unit for all singleton births (excluding twins and triplets) delivered in Brisbane between 1 July 2005 and 30 June 2009. We obtained weather data (including hourly relative humidity, minimum and maximum temperature) and air-pollution data (including PM10, SO2 and O3) from the Queensland Department of Environment and Resource Management. We used survival analyses with the time-dependent variables of temperature, humidity and air pollution, and the competing risks of stillbirth and live birth. To assess the monthly pattern of the birth outcomes, we fitted month of pregnancy as a time-dependent variable. We examined the seasonal pattern of the birth outcomes and the relationship between exposure to high or low temperatures and birth outcomes over the four lag weeks before birth. We further stratified by categorisation of PTB: extreme PTB (< 28 weeks of gestation), PTB (28–36 weeks of gestation), and term birth (≥ 37 weeks of gestation). Lastly, we examined the effect of temperature variation in each week of the pregnancy on birth outcomes. There was a bimodal seasonal pattern in gestation length. After adjusting for temperature, the seasonal pattern changed from bimodal, to only one peak in winter. The risk of stillbirth was statistically significant lower in March compared with January. After adjusting for temperature, the March trough was still statistically significant and there was a peak in risk (not statistically significant) in winter. There was an acute effect of temperature on gestational age and stillbirth with a shortened gestation for increasing temperature from 15 °C to 25 °C over the last four weeks before birth. For stillbirth, we found an increasing risk with increasing temperatures from 12 °C to approximately 20 °C, and no change in risk at temperatures above 20 °C. Certain periods of the pregnancy were more vulnerable to temperature variation. The risk of PTB (28–36 weeks of gestation) increased as temperatures increased above 21 °C. For stillbirth, the fetus was most vulnerable at less than 28 weeks of gestation, but there were also effects in 28–36 weeks of gestation. For fetuses of more than 37 weeks of gestation, increasing temperatures did not increase the risk of stillbirth. We did not find any adverse affects of cold temperature on birth outcomes in this cohort. My findings contribute to knowledge of the relationship between temperature and birth outcomes. In the context of climate change, this is particularly important. The results may have implications for public health policy and planning, as they indicate that pregnant women would decrease their risk of adverse birth outcomes by avoiding exposure to high temperatures and seeking cool environments during hot days.

Assessment of preterm infants' readiness to commence breastfeeding

Preterm infants commence breastfeeding when health-care professionals deem them to be ready. However, the optimal timing for commencement of breastfeeding is unclear. Currently, there is little guidance for neonatal care providers to decide when to initiate breastfeeding among preterm infants. A mixed-methods study was conducted to develop and test the Preterm Sucking Readiness (PTSR) scale in four phases. The first phase involved a chart audit to explore the use of age as a criterion by investigating when preterm infants meet feeding milestones as well as other factors that may affect an infant’s readiness to engage in nutritive sucking behaviour. The second phase utilised focus groups to explore and define how neonatal care providers decide when to commence breastfeeding. To gain consensus on the criteria mentioned by the focus groups, a Delphi survey was conducted in phase 3, involving neonatal providers across Australia and New Zealand. Phase 4 of the study involved an observational study that was used to test the six-item PTSR. The age at which specific feeding milestones were reached was consistent with what has been previously described in the literature. The chart audit showed that the time taken to the first feeding attempt in the preterm infant population was affected by gestational age at birth, birth weight, and specific interventions. Staff also considered age along with other criteria when deciding when to initiate feeding. Consensus on nine criteria for inclusion into the six-item PTSR was achieved using the Delphi technique. Three items of PTSR showed significant differences between the preterm and fullterm infant groups. Only two items, feeding-readiness behaviour and low pulse oximetry during handling, explained the variance in breastfeeding behaviour. The inter-rater variability ranged between moderate and very good for the PTSR items. The results of this study indicate the importance of assessing behavioural cues as an indication of breastfeeding readiness in the preterm infant population, once an infant is deemed physiologically stable. Age continues to be a factor in some clinicians' decisions to commence breastfeeding. However, age alone cannot be used to decide if an infant is ready to engage in breastfeeding. Further research is needed to confirm these findings.

Exercise in obese pregnant women: The role of social factors, lifestyle and pregnancy symptoms

Background Physical activity may reduce the risk of adverse maternal outcomes, yet there are very few studies that have examined the correlates of exercise amongst obese women during pregnancy. We examined which relevant sociodemographic, obstetric, and health behaviour variables and pregnancy symptoms were associated with exercise in a small sample of obese pregnant women. Methods This was a secondary analysis using data from an exercise intervention for the prevention of gestational diabetes in obese pregnant women. Using the Pregnancy Physical Activity Questionnaire (PPAQ), 50 obese pregnant women were classified as "Exercisers" if they achieved ≥900 kcal/wk of exercise and "Non-Exercisers" if they did not meet this criterion. Analyses examined which relevant variables were associated with exercise status at 12, 20, 28 and 36 weeks gestation. Results Obese pregnant women with a history of miscarriage; who had children living at home; who had a lower pre-pregnancy weight; reported no nausea and vomiting; and who had no lower back pain, were those women who were most likely to have exercised in early pregnancy. Exercise in late pregnancy was most common among tertiary educated women. Conclusions Offering greater support to women from disadvantaged backgrounds and closely monitoring women who report persistent nausea and vomiting or lower back pain in early pregnancy may be important. The findings may be particularly useful for other interventions aimed at reducing or controlling weight gain in obese pregnant women.

Depression: an emotional obstacle to seeking medical advice for infertility

Objective: To investigate the mental and general health of infertile women who had not sought medical advice for their recognized infertility and were therefore not represented in clinical populations. Design: Longitudinal cohort study.Setting Population based.Patient(s) Participants in the Australian Longitudinal Study on Women's Health aged 28-33 years in 2006 who had ever tried to conceive or had been pregnant (n = 5,936).Intervention(s) None.Main Outcome Measure(s) Infertility, not seeking medical advice. Result(s): Compared with fertile women (n = 4,905), infertile women (n = 1,031) had higher odds of self-reported depression (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.01-1.43), endometriosis (5.43, 4.01-7.36), polycystic ovary syndrome (9.52, 7.30-12.41), irregular periods (1.99, 1.68-2.36), type II diabetes (4.70, 1.79-12.37), or gestational diabetes (1.66, 1.12-2.46). Compared with infertile women who sought medical advice (n = 728), those who had not sought medical advice (n = 303) had higher odds of self-reported depression (1.67, 1.18-2.37), other mental health problems (3.14, 1.14-8.64), urinary tract infections (1.67, 1.12-2.49), heavy periods (1.63, 1.16-2.29), or a cancer diagnosis (11.33, 2.57-49.89). Infertile women who had or had not sought medical advice had similar odds of reporting an anxiety disorder or anxiety-related symptoms. Conclusion(s): Women with self-reported depression were unlikely to have sought medical advice for infertility. Depression and depressive symptoms may be barriers to seeking medical advice for infertility.