Waist circumference, waist-hip ratio and BMI and their correlation with cardiovascular risk factors in Australian adults

Objectives. To compare body mass index (BMI), waist circumference and waist–hip ratio (WHR) as indices of obesity and assess the respective associations with type 2 diabetes, hypertension and dyslipidaemia.

Design and setting. A national sample of 11 247 Australians aged ≥25 years was examined in 2000 in a cross-sectional survey.

Main outcome measures. The examination included a fasting blood sample, standard 2-h 75-g oral glucose tolerance test, blood pressure measurements and questionnaires to assess treatment for dyslipidaemia and hypertension. BMI, waist circumference and WHR were measured to assess overweight and obesity.

Results. The prevalence of obesity amongst Australian adults defined by BMI, waist circumference and WHR was 20.8, 30.5 and 15.8% respectively. The unadjusted odds ratio for the fourth vs. first quartile of each obesity measurement showed that WHR had the strongest relationship with type 2 diabetes, dyslipidaemia (women only) and hypertension. Following adjustment for age, however, there was little difference between the three measures of obesity, with the possible exceptions of hypertension in women, where BMI had a stronger association, and dyslipidaemia in women and type 2 diabetes in men, where WHR was marginally superior.

Conclusions. Waist circumference, BMI and WHR identified different proportions of the population, as measured by both prevalence of obesity and cardiovascular disease (CVD) risk factors. Whilst WHR had the strongest correlations with CVD risk factors before adjustment for age, the three obesity measures performed similarly after adjustment for age. Given the difficulty of using age-adjusted associations in the clinical setting, these results suggest that given appropriate cut-off points, WHR is the most useful measure of obesity to use to identify individuals with CVD risk factors.

Putting woman-centered care into practice : a new (ANEW) approach to psychosocial risk assessment during pregnancy

Background: When antenatal care is provided, identification and management of challenging problems, such as depression, domestic violence, child abuse, and substance abuse, are absent from traditional midwifery and medical training. The main objective of this project was to provide an alternative to psychosocial risk screening in pregnancy by offering a training program (ANEW) in advanced communication skills and common psychosocial issues to midwives and doctors, with the aim of improving identification and support of women with psychosocial issues in pregnancy.

Methods: ANEW used a before‐and‐after survey design to evaluate the effects of a 6‐month educational intervention for health professionals. The setting for the project was the Mercy Hospital for Women in Melbourne, Australia. Surveys covered issues, such as perceived competency and comfort in dealing with specific psychosocial issues, self‐rated communication skills, and open‐ended questions about participants' experience of the educational program.

Results: Educational program participants (n = 22/27) completed both surveys. After the educational intervention, participants were more likely to ask directly about domestic violence (p = 0.05), past sexual abuse (p = 0.05), and concerns about caring for the baby (p = 0.03). They were less likely to report that psychosocial issues made them feel overwhelmed (p = 0.01), and they reported significant gains in knowledge of psychosocial issues, and competence in dealing with them. Participants were highly positive about the experience of participating in the program.

Conclusions:The program increased the self‐reported comfort and competency of health professionals to identify and care for women with psychosocial issues.

Dietary protein level interacts with ω-3 polyunsaturated fatty acid deficiency to induce hypertension

Background : Dietary ω-3 fatty acid deficiency can lead to hypertension in later life; however, hypertension is affected by numerous other dietary factors. We examined the effect of altering the dietary protein level on blood pressure in animals deficient or sufficient in ω-3 fatty acids.

Methods : Female rats were placed on one of four experimental diets 1 week prior to mating. Diets were either deficient (10% safflower oil; DEF) or sufficient (7% safflower oil, 3% flaxseed oil; SUF) in ω-3 fatty acids and contained 20 or 30% casein (DEF20, SUF20, DEF30, SUF30). Offspring were maintained on the maternal diet for the duration of the experiment. At 12, 18, 24, and 30 weeks, blood pressure was assessed by tail cuff plethysmography.

Results : At both 12 and 18 weeks of age, no differences in blood pressure were observed based on diet, however, by 24 weeks hypertension was evident in DEF30 animals; there were no blood pressure differences between the other groups. This hypertension in DEF30 group was increased at 30 weeks, with systolic, diastolic, and mean arterial pressure all elevated.

Conclusions : These results indicate that the hypertension previously attributed to ω-3 fatty acid deficiency is dependent on additional dietary factors, including protein content. Furthermore, this study is the first to plot the establishment of ω-3 fatty acid deficiency hypertension over time.

A prospective study of factors that lead to body dissatisfaction during pregnancy

This study examined changes in body image and predictors of body dissatisfaction during pregnancy. It was expected that higher levels of depression, social comparison tendencies, teasing, societal pressure to be thin and public self-consciousness would predict body dissatisfaction prospectively. Healthy pregnant women (n = 128) completed questionnaires on three occasions during their pregnancies reporting on a total of four time points: 3 months prior to pregnancy (retrospectively reported), in the early to mid-second trimester, the late-second/early-third trimester, and the latter part of the third trimester. For the most part women reported adapting to the changes that occurred in their body; however, women were most likely to experience higher levels of body dissatisfaction in early to mid-second trimester. Findings related to predictors of body dissatisfaction revealed that both social and psychological factors contributed to body image changes in pregnancy. Implications of the findings are discussed.

Implementation of clinical practice guidelines using simulation in education

Background: Underpinning the Department of Human Services (DHS) “Future directions for Victoria’s maternity services” strategy in Victoria, are the principles of achieving the right balance between primary level care and access to appropriate levels of medical care by making the best use of the complementary skills of midwives, GPs and obstetricians. Planning new models of care have exposed a need to upskill many clinicians in providing evidence based pregnancy care. A statewide education program conducts 1 day workshops to multidisciplinary forums in Victoria. The program content is developed with each service and simulation activities are incorporated in the workshop to provide a realistic environment for practising skills related to the implementation of clinical practice guidelines.

Method: Post workshop surveys are completed anonymously by participants using a five point Likert scale to evaluate their experiences in peer learning, the use of simulation, reflective practice and communication skills training. Open ended responses were analysed thematically.

Results: In 2007, 14 workshops were conducted with 254 clinicians attending. The survey response rate was 80%. Participants responded ‘strongly agree’ or ‘agree’ that the workshop: enhanced their ability to access current pregnancy care research and information 193/ 204(95%), challenged them to think more broadly 192/204(94%), provided an opportunity to reflect on their communication skills during the simulation actives 197/201 (96%) and provided a valuable opportunity for observing the communication skills of their peers 197/ 201(98%).

Conclusion: Providing opportunities for peer learning in pregnancy education is valuable and the use of simulation can play an important role in overcoming barriers to implementing guidelines.

Hypertension induced by ω-3 polyunsaturated fatty acid deficiency is alleviated by α-linolenic acid regardless of dietary source

Ω-3 polyunsaturated fatty acid deficiency, particularly during the prenatal period, can cause hypertension in later life. This study examined the effect of different sources of α-linolenic acid (canola oil or flaxseed oil) in the prevention of hypertension and other metabolic symptoms induced by an ω-3 fatty acid-deficient diet. Dams were provided one of three experimental diets from 1 week before mating. Diets were either deficient (10% safflower oil-DEF) or sufficient (7% safflower oil+3% flaxseed oil-SUF-F; or 10% canola oil-SUF-C) in ω-3 fatty acids. The male offspring were continued on the maternal diet from weaning for the duration of the study. Body weight, ingestive behaviors, blood pressure, body composition, metabolic rate, plasma leptin and brain fatty acids were all assessed. The DEF animals were hypertensive at 24 weeks of age compared with SUF-F or SUF-C animals; this was not evident at 12 weeks. These results suggest that different sources of ALA are effective in preventing hypertension related to ω-3 fatty acid deficiency. However, there were other marked differences between the DEF and, in particular, the SUF-C phenotype including lowered body weight, adiposity, leptin and food intake in SUF-C animals. SUF-F animals also had lower, but less marked reductions in adiposity and leptin compared with DEF animals. The differences observed between DEF, SUF-F and SUF-C phenotypes indicate that body fat and leptin may be involved in ω-3 fatty acid deficiency hypertension.

Depression and anxiety through pregnancy and the early postpartum : an examination of prospective relationships

Background: The aim of this study was to explore the prospective relationship between depressive symptoms and anxiety across pregnancy and the early postpartum.
Methods: Participants (N=207) completed the State–Trait Anxiety Inventory Trait subscale, Beck Depression Inventory, and social support and sleep quality measures at two time points during pregnancy and once in the early postpartum period.
Results: After accounting for the relative stability of anxiety and depression over time, depressive symptoms earlier in pregnancy predicted higher levels of anxiety in late pregnancy and anxiety in late pregnancy predicted higher depressive symptomatology in the early postpartum. A bi-directional model of depression and anxiety in pregnancy was supported.
Limitations: Data were based on self-reports and participating women were predominantly tertiary educated with high family incomes.
Conclusion: Our findings suggest that depressive symptoms precede the development of higher levels of anxiety and that anxiety, even at non-clinical levels, can predict higher depressive symptoms. Clinicians are advised to screen for anxiety and depression concurrently during pregnancy.

Neonatal growth outcomes at birth and one month postpartum following in utero exposure to antidepressant medication

Objective: There is evidence of increasing prescription of antidepressant medication in pregnant women. This has arisen from the recognition of the importance of treating maternal depression. This must be balanced, however, with information on outcomes for infants and children exposed to antidepressants in pregnancy. The aim of the present study was to examine whether neonatal outcomes including gestational age at birth, neonatal growth outcomes at birth and then at 1 month postpartum were altered by in utero exposure to antidepressant medication using a prospective and controlled design.

Method: A prospective case–control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy at an obstetric hospital in Melbourne, Australia. Of the 27 women taking medication, 25 remained on medication in the third trimester. A purpose-designed self-report questionnaire and the Beck Depression Inventory-II were completed in pregnancy, after birth and at one month postpartum. In addition information was collected on exposed and non-exposed infants including Apgar scores, birthweight/length/head circumference and gestational age at birth. Weight/length/head circumference was again collected at 1 month of age.

Results: Infants exposed to antidepressants in utero were eightfold more likely to be born at a premature gestational age, had significantly lower birthweight and were smaller in length and head circumference than non-exposed infants. There was no association between birth outcomes and maternal depression. At 1 month, the difference in weight in the exposed group became significantly greater than the control group.

Conclusion: Antidepressant exposure in utero may affect gestational age at birth and neonatal outcomes independently of antenatal maternal depression. Further studies are needed to examine whether these findings vary according to the type of antidepressant prescribed and follow up growth and development in exposed infants beyond 1 month.

Continuity of midwifery care and gestational weight gain in obese women : a randomised controlled trial

Background: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women’s experience of pregnancy care; women’s satisfaction with care and a range of psychological factors.
Methods/Design: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI≥30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include sociodemographic information and the use of validated scales to measure secondary outcomes.
Discussion: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes.

Protocol for a randomized controlled trial of a specialized health coaching intervention to prevent excessive gestational weight gain and postpartum weight retention in women : the HIPP study

Background

Pregnancy is a time of significant physiological and physical change for women. In particular, it is a time at which many women are at risk of gaining excessive weight. We describe the rationale and methods of the Health in Pregnancy and Post-birth (HIPP) Study, a study which aims primarily to determine the effectiveness of a specialized health coaching (HC) intervention during pregnancy, compared to education alone, in preventing excessive gestational weight gain and postpartum weight retention 12 months post birth. A secondary aim of this study is to evaluate the mechanisms by which our HC intervention impacts on weight management both during pregnancy and post birth.
Methods/Design

The randomized controlled trial will be conducted with 220 women who have a BMI > 18.5 (American IOM cut-off for normal weight), are 18 years of age or older, English speaking, no history of disordered eating or diabetes and are less than 18 weeks gestation at recruitment. Women will be randomly allocated to either a specialized HC intervention group or an Education Alone group. Our specialized HC intervention has two components: (1) one-on-one sessions with a Health Coach, and (2) two by two hour educational group sessions led by a Health Coach. Women in the Education Alone group will receive two by two hour educational group sessions with no HC components. Body Mass Index, waist circumference, and psychological factors including motivation, readiness to change, symptoms of depression and anxiety, and body dissatisfaction will be assessed at baseline (14-16 weeks gestation), and again at follow-up: 32 weeks gestation, 6 weeks, 6 months and 12 months postpartum.
Discussion

Our study responds to the urgent need to design effective interventions in pregnancy to prevent excessive gestational weight gain and postpartum weight retention. Our pregnancy HC intervention is novel and innovative and has been designed to be easily adopted by health professionals who work with pregnant women, such as obstetricians, midwives, allied health professionals and health psychologists.

Maternal dietary intake during pregnancy has longstanding consequences for the health of her offspring

Over the past 100 years, advances in pharmaceutical and medical technology have reduced the burden of communicable disease, and our appreciation of the mechanisms underlying the development of noncommunicable disease has broadened. During this time, a number of studies, both in humans and animal models, have highlighted the importance of maintaining an optimal diet during pregnancy. In particular, a number of studies support the hypothesis that suboptimal maternal protein and fat intake during pregnancy can have long-term effects on the growing fetus, and increase the likelihood of these offspring developing cardiovascular, renal, or metabolic diseases in adulthood. More recently, it has been shown that dietary intake of a number of micronutrients may offset or reverse the deleterious effects of macronutrient imbalance. Furthermore, maternal fat intake has also been identified as a major contributor to a healthy fetal environment, with a beneficial role for unsaturated fats during development as well as a beneficial impact on cell membrane physiology. Together these studies indicate that attempts to optimise maternal nutrition may prove to be an efficient and cost-effective strategy for preventing the development of cardiovascular, renal, or metabolic diseases.

The role of blood pressure in glaucoma

Although intraocular pressure (IOP) remains an important risk factor for glaucoma, it is clear that other factors can also influence disease development and progression. More recently, the role that blood pressure (BP) has in the genesis of glaucoma has attracted attention, as it represents a clinically modifiable risk factor and thus provides the potential for new treatment strategies beyond IOP reduction. The interplay between blood pressure and IOP determines the ocular perfusion pressure (OPP), which regulates blood flow to the optic nerve. If OPP is a more important determinant of ganglion cell injury than IOP, then hypotension should exacerbate the detrimental effects of IOP elevation, whereas hypertension should provide protection against IOP elevation. Epidemiological evidence provides some conflicting outcomes of the role of systemic hypertension in the development and progression of glaucoma. The most recent study showed that patients at both extremes of the blood pressure spectrum show an increased prevalence of glaucoma. Those with low blood pressure would have low OPP and thus reduced blood flow; however, that people with hypertension also show increased risk is more difficult to reconcile. This finding may reflect an inherent blood flow dysregulation secondary to chronic hypertension that would render retinal blood flow less able to resist changes in ocular perfusion pressure. Here we review both clinical and experimental studies that have attempted to clarify the relationships among blood pressure, OPP and blood flow autoregulation in the pathogenesis of glaucoma.

Short term fat feeding rapidly increases plasma insulin but does not result in dyslipidaemia

Although the association between obesity and hypertension is well known, the underlying mechanism remains elusive. Previously, we have shown that 3 week fat feeding in rabbits produces greater visceral adiposity, hypertension, tachycardia and elevated renal sympathetic nerve activity compared to rabbits on a normal diet. Because hyperinsulinaemia, hyperleptinemia and dyslipidaemia are independent cardiovascular risk factors associated with hypertension we compared plasma insulin, leptin and lipid profiles in male New Zealand White rabbits fed a normal fat diet (NFD 4.3% fat, n = 11) or high fat diet (HFD 13.4% fat, n = 13) at days 1, 2, 3 and weeks 1, 2, 3 of the diet. Plasma concentrations of diacylglyceride (DG), triacylglyceride (TG), ceramide and cholesteryl esters (CE) were obtained after analysis by liquid chromatography mass spectrometry. Plasma insulin and glucose increased within the first 3 days of the diet in HFD rabbits (P <0.05) and remained elevated at week 1 (P <0.05). Blood pressure and heart rate followed a similar pattern. By contrast, in both groups, plasma leptin levels remained unchanged during the first few days (P >0.05), increasing by week 3 in fat fed animals alone (P <0.05). Concentrations of total DG, TG, CE and Ceramide at week 3 did not differ between groups (P >0.05). Our data show plasma insulin increases rapidly following consumption of a HFD and suggests that it may play a role in the rapid rise of blood pressure. Dyslipidaemia does not appear to contribute to the hypertension in this animal model.

Effects of ATP7A overexpression in mice on copper transport and metabolism in lactation and gestation

Placentae and mammary epithelial cells are unusual in robustly expressing two copper "pumps", ATP7A and B, raising the question of their individual roles in these tissues in pregnancy and lactation. Confocal microscopic evidence locates ATP7A to the fetal side of syncytiotrophoblasts, suggesting a role in pumping Cu towards the fetus; and to the basolateral (blood) side of lactating mammary epithelial cells, suggesting a role in recycling Cu to the blood. We tested these concepts in wild-type C57BL6 mice and their transgenic counterparts that expressed hATP7A at levels 10-20× those of endogenous mAtp7a. In lactation, overexpression of ATP7A reduced the Cu concentrations of the mammary gland and milk ~50%. Rates of transfer of tracer (64)Cu to the suckling pups were similarly reduced over 30-48 h, as was the total Cu in 10-day -old pups. During the early and middle periods of gestation, the transgenic litters had higher Cu concentrations than the wild-type, placental Cu showing the reverse trend; but this difference was lost by the first postnatal day. The transgenic mice expressed ATP7A in some hepatocytes, so we investigated the possibility that metalation of ceruloplasmin (Cp) might be enhanced. Rates of (64)Cu incorporation into Cp, oxidase activity, and ratios of holo to apoceruloplasmin were unchanged. We conclude that in the lactating mammary gland, the role of ATP7A is to return Cu to the blood, while in the placenta it mediates Cu delivery to the fetus and is the rate-limiting step for fetal Cu nutrition during most of gestation in mice.