Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies

Background/objectiveThere is no international consensus about the optimal approach to screening and diagnosis of gestational diabetes mellitus (GDM). Fasting plasma glucose (FPG) has been proposed as an alternative universal screening test to simplify the diagnosis of GDM. We investigate the ability of the FPG to predict a 2-hour glucose value below the cut-off for GDM, thereby “ruling out” the necessity of a full OGTT and assess the proportion of GDM-related complications associated with the identified FPG level.Materials and methodsThis study included secondary data from four Norwegian pregnancy cohorts (2002-2013), encompassing 2960 women universally screened with late mid-pregnancy 75g OGTT measuring FPG and 2-hour glucose. For a range of FPG thresholds, we calculated sensitivity to predict elevated 2-hour glucose, number of OGTTs needed and percentage of GDM cases missed, applying modified World Health Organization (WHO) 2013 criteria (2013WHO) and 2017 Norwegian criteria (2017Norwegian). We analyzed pregnancy outcomes for women above and below our selected threshold.ResultsThe prevalence of GDM was 16.6% (2013WHO) and 10.1% (2017Norwegian). A FPG threshold of 4.7 mmol/L had a sensitivity of 76% (2013WHO) and 80% (2017Norwegian) for detecting elevated 2-hour glucose, with few missed GDM cases (2.0% of those ruled out and 7.5% of all GDM cases for 2013WHO, and 1.1% of those ruled out and 7% of all GDM cases for 2017Norwegian). When excluding women with FPG <4.7mmol/l and those with GDM based on FPG, only 24% (2013WHO) and 29% (2017Norwegian) would require OGTT. Women with FPG <4.7mmol/l, including missed GDM cases, had low risk of large-for-gestational-age newborns, cesarean section and operative vaginal delivery.ConclusionA FPG threshold of 4.7mmol/l as a first step when screening for GDM could potentially eliminate the need for OGTT in 70-77% of pregnancies. Women with FPG below this threshold appear to carry low risk of GDM-associated adverse pregnancy outcomes

Family meal participation is associated with dietary intake among 12-month-olds in Southern Norway

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Changes in fruit and vegetable consumption habits from pre-pregnancy to early pregnancy among Norwegian women

Background: A healthy diet is important for pregnancy outcome and the current and future health of woman and child. The aims of the study were to explore the changes from pre-pregnancy to early pregnancy in consumption of fruits and vegetables (FV), and to describe associations with maternal educational level, body mass index (BMI) and age. Methods: Healthy nulliparous women were included in the Norwegian Fit for Delivery (NFFD) trial from September 2009 to February 2013, recruited from eight antenatal clinics in southern Norway. At inclusion, in median gestational week 15 (range 9–20), 575 participants answered a food frequency questionnaire (FFQ) where they reported consumption of FV, both current intake and recollection of pre-pregnancy intake. Data were analysed using a linear mixed model. Results: The percentage of women consuming FV daily or more frequently in the following categories increased from pre-pregnancy to early pregnancy: vegetables on sandwiches (13 vs. 17%, p <0.01), other vegetables (11 vs. 14%, p = 0.01), fruits (apples, pears, oranges or bananas) (24 vs. 41%, p < 0.01), other fruits and berries (8 vs. 15%, p < 0.01) and fruits and vegetables as snacks (14 vs. 28%, p < 0.01). The percentage of women who reported at least daily consumption of vegetables with dinner (22% at both time points) was stable. A higher proportion of older women increased their consumption of vegetables and fruits as snacks from pre-pregnancy to early pregnancy compared to younger women (p=0.04). Conclusions: We found an increase in the proportion of women consuming FV daily or more frequently from pre-pregnancy to early pregnancy. Trial registration: ClinicalTrials.gov database, NCT01001689. https://clinicaltrials.gov/ct2/show/ NCT01001689?term=NCT01001689&rank=1. Keywords: Fruits, Preconception, Pregnancy, VegetablespublishedVersionNivå

How does a lifestyle intervention during pregnancy influence perceived barriers to leisure-time physical activity? The Norwegian fit for delivery study, a randomized controlled trial

Background: To develop effective health promotional and preventive prenatal programs, it is important to understand perceived barriers to leisure-time physical activity during pregnancy, including exercise and sport participation. The aims of the present study was 1) to assess the effect of prenatal lifestyle intervention on the perceived barrier to leisure-time physical activity during pregnancy and the first year after delivery and 2) identify the most important perceived barriers to leisure-time physical activity at multiple time points during and after pregnancy. Methods: This secondary analysis was part of the Norwegian Fit for Delivery study, a combined lifestyle intervention evaluated in a blinded, randomized controlled trial. Healthy, nulliparous women with singleton pregnancy of ≤20 gestational weeks, age ≥ 18 years and body mass index ≥19 kg/m2 were recruited via healthcare clinics in southern Norway, including urban and rural settings. Participants were randomized to either twice-weekly supervised exercise sessions and nutritional counselling (n = 303) or standard prenatal care (n = 303). The principal analysis was based on the participants who completed the standardized questionnaire assessing their perceived barriers to leisure-time physical activity at inclusion (gestational week 16, n = 589) and following intervention (gestational week 36, n = 509), as well as six months (n = 470) and 12 months (n = 424) postpartum. Results: Following intervention (gestation week 35.4 ± 1.0), a significant between-group difference in perceived barriers to leisure-time physical activity was found with respect to time constraints: “... I do not have the time” (intervention: 22 vs. control: 38, p = 0.030), mother-child safety concerns: “... afraid to harm the baby” (intervention: 8 vs. control: 25, p = 0.002) and self-efficacy: “... I do not believe/think that I can do it” (intervention: 3 vs. control: 10, p = 0.050). No positive effect was seen at postpartum follow-up. Intrapersonal factors (lack of time, energy and interest) were the most frequently perceived barriers, and consistent over time among all participants. Conclusion: The intervention had effect on intrapersonal perceived barriers in pregnancy, but not in the postpartum period. Perceived barriers to leisure-time physical activity were similar from early pregnancy to 12 months postpartum.publishedVersionNivå

Evaluation of implementing a community-based exercise intervention during pregnancy

Objective: To evaluate the implementation of a community-based exercise intervention (the Norwegian Fit for Delivery study) during pregnancy. Design: Descriptive, explorative. Setting: Healthcare clinics in southern Norway, including urban and rural settings. Participants: Healthy, nulliparous women with singleton pregnancy of ≤20 gestational weeks, age ≥18 years and body mass index ≥19 kg/m2. Methods: Women were randomized to either twice-weekly supervised exercise sessions combined with nutritional counselling (n=303) or standard prenatal care (n=303). The exercise program was based on ACOG guidelines, with the same low-impact workout for all participants, including 60 minutes of moderate-intensity cardiovascular and strength training, performed in a group of maximum 25 women. The aim of the present secondary analysis was to report on the intervention group's experience with participating in an exercise program in the 2nd and 3rd trimester, including satisfaction, adherence, adverse effects, as well as motives and barriers for attending the classes. Results: Of 303 women randomized to exercise, 274 (92.6%) attended at least one class and 187 (68.2%) completed a questionnaire after completion of the trial assessing their experience with the group sessions. For 71.7%, self-reported exercise dosage was ≥75% of the twice-weekly exercise program and more than seven out of 10 reported to be satisfied or very satisfied with the exercise sessions. A total of 95.1% answered that they would recommend this type of exercise for pregnant friends. Reported motives and health benefits included better aerobic capacity, increased energy levels and exercise enjoyment. No harmful effects of the exercise intervention were noted in the mother or the fetus. Key conclusions and implications for practice: Results demonstrated that regular group exercise was feasible, safe, and well tolerated in pregnancy, which may encourage incorporating this program into a routine health care setting.acceptedVersionNivå

Change in active transportation and weight gain in pregnancy

Background: Pregnancy is characterised by large weight gain over a short period, and often a notable change in mode of transportation. This makes pregnancy suitable for examining the plausible, but in the scientific literature still unclear, association between active transportation and weight gain. We hypothesize that women continuing an active mode of transportation to work or school from pre- to early pregnancy will have a lower gestational weight gain (GWG) than those who change to a less active mode of transportation. Methods: We analysed prospective data from the Norwegian Fit for Delivery (NFFD) trial. Between September 2009 and February 2013 606 women were consecutively enrolled in median gestational week 16 (range; 8–20). Of 219 women who used an active mode of transportation (biking, walking, public transportation) pre-pregnancy, 66 (30 %) converted to a less active mode in early pregnancy (“active-less active” group), and 153 (70 %) continued with active transportation (“active-active” group). Pre-pregnancy weight was self-reported. Weight at gestational (GA) weeks 16, 30, 36, and at term delivery was objectively measured. Weight gain was compared between the two groups. Linear mixed effects analysis of the repeated weight measures was performed including the group*time interaction. Results: A significant overall group effect was observed for the four time points together (“active-active” group: 77.3 kg vs. “active-less active” group: 78.8 kg, p = 0.008). The interaction term group*time was significant indicating different weight gain throughout pregnancy for the two groups; the mean differences between the groups were 0.7 kg at week 16, 1.4 kg at week 30, 2.1 kg at week 36, and 2.2 kg at term delivery, respectively. Conclusion: The findings indicate that active transportation is one possible approach to prevent excessive weight gain in pregnancy. Keywords: Active transportation, Biking, BMI, Pregnancy, Public transportation, Walking, Weight gainpublishedVersio

Changes in mode of transportation to work or school from pre-pregnancy to early pregnancy in the Norwegian Fit for Delivery study

Objective To describe changes in mode of transportation to work or school from pre-pregnancy to early pregnancy, to describe levels of physical activity related to mode of transportation to work or school, and to examine associations between changes in mode of transportation to work or school and educational level, body mass index (BMI) and age. Methods Between September 2009 and February 2013, 575 healthy pregnant nulliparous women were included into the Norwegian Fit for Delivery (NFFD) trial. At inclusion they reported their current and their pre-pregnancy mode of transportation to work or school. Data were analysed by multilevel mixed models with dichotomized modes of transportation as dependent variables. Results There was a significant change towards less active transportation to work or school and a decrease in level of physical activity from pre-pregnancy to early pregnancy. Pre-pregnancy, 58% used private transportation to work or school, compared to 64% in early pregnancy (p = 0.001). The percentage of women who biked (11% v. 5%, p < 0.001) decreased significantly from pre-pregnancy to early pregnancy. Conclusions In this sample of Norwegian women there was a significant change towards less active transportation to work or school and lower levels of physical activity from pre-pregnancy to early pregnancy. Keywords: Active transportation, Biking, Commuting, IPAQ, MET-score, Physical activity, Pregnancy, Private transportation, Public transportation, WalkingpublishedVersio

Reliability and concurrent validity of the International Physical Activity Questionnaire short form among pregnant women

Background: The International Physical Activity Questionnaire short-form (IPAQ-SF) is frequently used to assess physical activity (PA) level in the general adult population including pregnant women. However, the reliability and validity of the questionnaire in pregnancy is unknown. Therefore, the aims of the present study were to investigate test-retest reliability and concurrent validity of IPAQ-SF among pregnant women, and whether PA is reported differently among those who fulfill (active) vs. do not fulfill (inactive) recommendations of ≥150 min of weekly moderate intensity PA in pregnancy. Method: Test-retest reliability was examined by answering IPAQ-SF twice, two weeks apart (n = 88). To assess validity, IPAQ-SF was compared to the physical activity monitor SenseWear Armband® (SWA) (n = 64). The participants wore SWA for 8 consecutive days before answering IPAQ-SF. PA level was reported as time spent in moderate-, vigorous- and moderate-to-vigorous intensity PA (MPA, VPA and MVPA) corresponding to the cut-off points 3–6, >6 and >3 Metabolic Equivalents (METs), respectively. Results: Test-retest intraclass-correlation of MPA, VPA and MVPA ranged from 0.81-0.84 (95% Confidence Intervals: 0.69,0.90). Comparing time spent performing PA at various intensities; the mean differences and limits of agreement (±1.96 Standard Deviation) from Bland-Altman plots were−84 ± 402 min/week for MPA,−85 ± 452 min/week for MVPA and 26 ± 78 min/week for VPA, illustrating that the total group under-reported MPA by 72% and MVPA by 52%, while VPA was over-reported by 1400%. For the inactive group corresponding numbers were 44 ± 327 min/week for MPA, 52 ± 355 min/week for MVPA and 16 ± 33 min/week for VPA, illustrating that the inactive group over-reported MPA by 13% and MVPA by 49%, while VPA was not detected by SWA, but participants reported 16 min of VPA/week. In contrast, corresponding numbers for the active group were−197 ± 326 min/week for MPA,−205 ± 396 min/week for MVPA and 35 ± 85 min/week for VPA, illustrating that the active group under-reported MPA by 81% and MVPA by 60%, while they over-reported VPA by 975%. Conclusion: IPAQ-SF had good test-retest reliability, but low to fair concurrent validity for MPA, VPA and MVPA compared to an objective criterion measure among pregnant women. Further, women fulfilling PA guidelines in pregnancy under-reported, while inactive women over-reported PA level.publishedVersionNivå

Study protocol: differential effects of diet and physical activity based interventions in pregnancy on maternal and fetal outcomes--individual patient data (IPD) meta-analysis and health economic evaluation.

© 2014 Ruifrok et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.BACKGROUND: Pregnant women who gain excess weight are at risk of complications during pregnancy and in the long term. Interventions based on diet and physical activity minimise gestational weight gain with varied effect on clinical outcomes. The effect of interventions on varied groups of women based on body mass index, age, ethnicity, socioeconomic status, parity, and underlying medical conditions is not clear. Our individual patient data (IPD) meta-analysis of randomised trials will assess the differential effect of diet- and physical activity-based interventions on maternal weight gain and pregnancy outcomes in clinically relevant subgroups of women. METHODS/DESIGN: Randomised trials on diet and physical activity in pregnancy will be identified by searching the following databases: MEDLINE, EMBASE, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database. Primary researchers of the identified trials are invited to join the International Weight Management in Pregnancy Collaborative Network and share their individual patient data. We will reanalyse each study separately and confirm the findings with the original authors. Then, for each intervention type and outcome, we will perform as appropriate either a one-step or a two-step IPD meta-analysis to obtain summary estimates of effects and 95% confidence intervals, for all women combined and for each subgroup of interest. The primary outcomes are gestational weight gain and composite adverse maternal and fetal outcomes. The difference in effects between subgroups will be estimated and between-study heterogeneity suitably quantified and explored. The potential for publication bias and availability bias in the IPD obtained will be investigated. We will conduct a model-based economic evaluation to assess the cost effectiveness of the interventions to manage weight gain in pregnancy and undertake a value of information analysis to inform future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2013: CRD42013003804.This study was funded by the National Institute for Health Research (NIHR) HTA (Health Technology Assessment) UK programme 12/01