BMC Pediatr. 2013 May 20;13:80.

Pragmatic controlled trial to prevent childhood obesity in maternity and child health care clinics: pregnancy and infant weight outcomes (the VACOPP Study).

Mustila T, Raitanen J, Keskinen P, Saari A, Luoto R.

 

Abstract

BACKGROUND:

According to current evidence, the prevention of obesity should start early in life. Even the prenatal environment may expose a child to unhealthy weight gain; maternal gestational diabetes is known to be among the prenatal risk factors conducive to obesity. Here we report the effects of antenatal dietary and physical activity counselling on pregnancy and infant weight gain outcomes.

METHODS:

The study was a non-randomised controlled pragmatic trial aiming to prevent childhood obesity, the setting being municipal maternity health care clinics. The participants (n = 185) were mothers at risk of developing gestational diabetes mellitus and their offspring. The children of the intervention group mothers were born between 2009 and 2010, and children of the control group in 2008. The intervention started between 10-17 gestational weeks and consisted of individual counselling on diet and physical activity by a public health nurse, and two group counselling sessions by a dietician and a physiotherapist. The expectant mothers also received a written information leaflet to motivate them to breastfeed their offspring for at least 6 months. We report the proportion of mothers with pathological glucose tolerance at 26-28 weeks’ gestation, the mother’s gestational weight gain (GWG) and newborn anthropometry. Infant weight gain from 0 to 12 months of age was assessed as weight-for-length standard deviation scores (SDS) and mixed effect linear regression models.

RESULTS:

Intervention group mothers had fewer pathological oral glucose tolerance test results (14.6% vs. 29.2%; 95% CI 8.9 to 23.0% vs. 20.8 to 39.4%; p-value 0.016) suggesting that the intervention improved gestational glucose tolerance. Mother’s GWG, newborn anthropometry or infant weight gain did not differ significantly between the groups.

CONCLUSION:

Since the intervention reduced the prevalence of gestational diabetes mellitus, it may have the potential to diminish obesity risk in offspring. However, results from earlier studies suggest that the possible effect on the offspring’s weight gain may manifest only later in childhood.

TRIAL REGISTRATION:

Clinical Trials gov: NCT00970710.

PMID: 23688259

 

Supplement

Obesity tends to originate in early life and many of obese pre-schoolers become obese schoolchildren and adults. Because obesity is difficult to reverse even in childhood, the prevention of obesity is considered to be the most effective way to combat this major health problem.

Known modifiable risk factors in early life are mother’s obesity before pregnancy, as well as excessive weight gain, impaired glucose tolerance and smoking during pregnancy [1]. Moreover, the type of infant feeding, sleep duration and rapid weight gain during the first year of life are known risk factors for childhood obesity. Mother’s gestational diabetes (GDM) appears to increase the risk of obesity in offspring, even if the birth weight is normal [2]. Preventive efforts should start in early life. To improve the cost-effectiveness of a programme that is carried out in a health care system, it should target families at risk of having obese offspring. One such risk group is the offspring of mothers at risk of developing GDM.

The evidence from the obesity prevention programmes reported has shown that multifaceted intervention is more effective than targeting a single behaviour [3]. In this article we report the first results of an ongoing multifaceted controlled lifestyle intervention trial intended to prevent childhood obesity (The VACOPP, Vaasa Childhood Obesity Primary Prevention, Study) [4]. The intervention started during the first trimester of pregnancy and first targeted pregnant mothers at maternity health care clinics and then families until the offspring’s age of five years.

The ante-natal intervention consisted of two group counselling sessions by a trained physiotherapist and a dietician working in public health care given during the first and second trimesters of pregnancy. During the 13 routine visits to the maternity health care clinics starting from tenth week of pregnancy, the PHNs briefly recapped the counselling information provided during the group sessions.

The control group mothers had a significantly higher proportion of abnormal OGTT results than the intervention group (29.2% vs. 14.6%, p-value 0.016) (Table 1). According to a mixed effect linear regression model, the z-score slopes of infants’ weight-for-length did not differ significantly between the intervention and control groups (p-value 0.71) (Table 2).

 

Table 1. Secondary maternal and neonatal outcomes in the trial groups (mean or frequency and 95% CI)Taina Mustila-tab1aIndependent Samples T-test, bMann-Whitney U-test, cChi-Square Test; OGTT, oral glucose tolerance test (75 g glucose load, 2-hour); cP = capillary plasma glucose; CI, confidence interval

 

 

Table 2. Estimates and 95% confidence intervals for weight-for-length SDS from multilevel mixed-effects linear regression model Taina Mustila-tab2SDS, standard deviation score; non-linear relationship between SDS and age of the child was modelled using polynomial age in months 2; Group * Age = interaction between age of the child and the group

 

The results reported here suggest that the intervention in this trial may have the potential to improve glucose tolerance in pregnant mothers. The mothers were told that their lifestyle during pregnancy could have significant effects on the outcomes of the pregnancy and on their newborns, and also on the offspring’s weight development. We believe that this knowledge may have motivated the intervention mothers to make healthy dietary changes during pregnancy.

The study groups were comparable at baseline as characteristics possibly interfering in the offspring’s risk of obesity showed no statistically significant differences between the groups. We targeted a group of mothers at risk of developing GDM, thus making the possibility of the intervention effect higher. A limitation of this study was a non-randomized design.

Conclusions

The most natural setting in primary health care for obesity preventive interventions is maternity and child health care clinics, as this reaches the beginning of next generation. To find effective prevention programmes pragmatic trials in the real-life settings are needed. Our study appeared to improve glucose tolerance during pregnancy, suggesting its potential to have a positive effect on offspring weight gain. We failed to find any effect on newborn birth weight or infant weight gain, but research has shown that an adverse effect of gestational diabetes on the offspring’s weight gain tends to develop only later in childhood.

 

References

1. Dabelea D, Crume T: Maternal environment and the trans-generational cycle of obesity and diabetes. Diabetes 2011, 60:1849–1855.

2. Baptiste-Roberts K, Nicholson WK, Wang NY, Brancati FL: Gestational diabetes and subsequent growth patterns of offspring: the National Collaborative Perinatal Project. Matern Child Health J 2012, 16:125–132. Erratum in: Matern Child Health J 2012, 16:266.

3. Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD: Interventions for preventing obesity in children. Cochrane Database Syst Rev 2011, 7:CD001871.

4. Mustila T, Keskinen P, Luoto R: Behavioural counselling to prevent childhood obesity – study protocol of a pragmatic trial in maternity and child health care. BMC Pediatr 2012, 12:93.

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