Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-06-22T20:19:45Z No. of bitstreams: 1 RainaLima.pdf: 6488864 bytes, checksum: db557811216cf129eb2f4baa56f2046f (MD5) / Made available in DSpace on 2017-06-22T20:19:45Z (GMT). No. of bitstreams: 1 RainaLima.pdf: 6488864 bytes, checksum: db557811216cf129eb2f4baa56f2046f (MD5) Previous issue date: 2016-02-18 / Objective. This study aims to analyze the effects of prepregnancy nutritional status and gestational weight gain on birth weight. Methodology. Cross-sectional study involving 5,024 mothers and their newborns who participated in the study BRISA São Luís - MA. Data were collected in 2010 and were applied two questionnaires after delivery: one with maternal data and other newborn´s data. The main explanatory variables were prepregnancy BMI and gestational weight gain. Theoretical model was proposed to explain the total, direct and indirect effects, using structural equation modeling in the analysis, with adjustment for sociodemographic variables, life habits and maternal comorbidities, with the outcome birth weight. Results. The final model had good fit according to indicators RMSEA, CFI / TLI and WRMR. The prepregnancy BMI had total effect (Standardized Coefficient SC=0.126; p <0.001) and direct (SC=0.211; p <0.001) positive on the newborn's weight, plus negative indirect effect on the total gestational weight gain. Gestational weight gain in turn had the highest effect on birth weight (SC=0.280; p <0.001), including modifying the effect of other variables. Socioeconomic status, maternal age, more stable marital status and gestational diabetes had positive total effects, while high blood pressure and smoking during pregnancy had negative effects on birth weight. Alcohol use during pregnancy showed no total effect. Conclusion. Mothers with higher prepregnancy BMI can have children with higher weight, as well as those with high gestational weight gain. These associations highlight the need for greater attention to the health of women of reproductive age and maintaining proper weight gain during pregnancy, which could contribute to reducing risks of maternal complications and newborn. / Objetivo. O presente estudo teve por objetivo analisar os efeitos do estado nutricional pré-gestacional e ganho de peso gestacional no peso ao nascer. Metodologia. Estudo transversal que envolveu 5.024 mães e seus recém-nascidos que participaram do estudo BRISA de São Luís – MA. Os dados foram coletados no ano de 2010 e aplicaram-se dois questionários após o parto: um com dados da mãe e outro do recém-nascido. As variáveis explanatórias principais foram o IMC pré-gestacional e o ganho de peso gestacional. Modelo teórico foi proposto para explicar efeitos totais, diretos e indiretos, utilizando modelagem de equações estruturais na análise, com ajuste para variáveis sociodemográficas, hábitos de vida e comorbidades maternas, tendo como desfecho peso ao nascer. Resultados. O modelo final teve bom ajuste segundo os indicadores RMSEA, CFI/TLI e WRMR. O IMC pré-gestacional teve efeitos total (Coeficiente padronizado CP=0.126; p<0.001) e direto (CP=0.211; p<0.001) positivos no peso do recém-nascido, além de efeito indireto negativo via ganho de peso gestacional total. O ganho de peso gestacional por sua vez apresentou o maior efeito no peso de nascimento (CP=0.280; p<0.001), inclusive modificando o efeito de outras variáveis. Situação socioeconômica, idade materna, situação conjugal mais estável e diabetes gestacional tiveram efeitos totais positivos, enquanto que hipertensão arterial e tabagismo na gestação apresentaram efeitos negativos no peso ao nascer. Uso de álcool durante a gestação não apresentou efeito total. Conclusão. Mães com maior IMC pré-gestacional podem gerar filhos com mais alto peso, assim como aquelas com elevado ganho de peso total. Essas associações ressaltam a necessidade de maior atenção à saúde de mulheres em idade reprodutiva e manutenção do ganho de peso adequado durante a gestação, o que poderá contribuir para a diminuição de riscos de intercorrências maternas e do recém-nascido.

No description available.

Background: Although lifestyle modification is the cornerstone of GDM management, the evidence base on which dietary recommendations to prevent GDM is diverse and has not been synthesized in a consistent fashion. Objectives: The overall objective of this thesis is to assess the relationship of diet patterns, foods, and nutrients with GDM risk. Specifically, we seek to: 1) Quantify the relationship between dietary factors and GDM and metabolic disorders of pregnancy; 2) Compare the effects of dietary factors on markers of glycemic control, such as fasting glucose, fasting insulin, HbA1c, and the homeostatic model assessment for insulin resistance (HOMA-IR); 3) Assess the association and interaction between carbohydrate quality, and genetic load on the risk of developing GDM using data from 2 prospective birth cohort studies. Methods: We follow the approach set by the Cochrane Group’s Handbook for Systematic Review of Interventions to conduct meta-analyses and assess the quality of the evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. We analyze prospective cohort data of 2,504 women from the CHILD and START studies, which enrolled women of White-Caucasian and South Asian ethnicity. We quantify carbohydrate quality by deriving the glycemic index and load (GL), and total and added sugar intake. We construct a gene score using 102 loci that were previously associated with type 2 diabetes in genome-wide association studies. Results: 1) The meta-analysis identified high-quality evidence that red meat increases GDM risk; however, most associations of foods and nutrients with GDM and other metabolic disorders of pregnancy are of low-quality; 2) The network meta-analysis identified that most dietary interventions given with gestational weight gain advice will lower fasting glucose; 3) In South Asians, a high GL coupled with a high genetic load increased GDM risk six fold, but a high total sugar intake in the presence of a high genetic load reduced GDM risk. This paradoxical finding may be explained by a high correlation between total sugars and other healthy foods. Conclusions: Few valid associations between dietary factors and GDM risk exist. GL and total sugars may modify the genetic risk of GDM in South Asians but not in White-Caucasians. Further research is needed to determine effective interventions that can assist women in adopting healthier eating habits during pregnancy. / Thesis / Doctor of Philosophy (PhD) / Gestational diabetes mellitus (GDM) is glucose intolerance that first appears during pregnancy. Although lifestyle modification is the cornerstone of GDM management, dietary recommendations for GDM prevention are sparse. The overarching objective of this thesis is to describe the relationships between diets, foods, and nutrients and GDM and metabolic disorders of pregnancy and to understand whether carbohydrate quality can modify a genetic predisposition to diabetes. In the systematic literature reviews, high-quality evidence showed that red meat increases GDM risk. Moderate-quality evidence showed that several dietary factors also influence the risk of GDM and metabolic disorders of pregnancy, but most of the existing evidence is of low-quality. More high-quality studies are needed before dietary interventions can be implemented In our genetic study, we observed that carbohydrate quality may modify the genetic risk of diabetes in South Asians but not in White-Caucasians and conclude that carbohydrate quality may provide only a limited assessment of overall diet quality.

This dissertation is a collection of three separate essays on the health of women and children. In the first essay, I along with my co-authors, analyzed the impact of two large, national-level health policies (the Janani Suraksha Yojana (JSY) and the National Rural Health Mission (NRHM)) on maternal health outcomes (proportion of institutional deliveries) in India. We used data from the India Human Development Survey (IHDS) and found that the JSY and the NRHM had a greater impact on institutional deliveries in high-focus states. We also found that the conditions of the public health facilities, did not change after the implementation of the JSY and the NRHM. Finally, we found that adequacy of health facilities was not associated with the likelihood of mothers in high-focus states having an institutional delivery. In the second essay, I examined whether a key social determinant of health in South Asia- gender inequality, is associated with physical health outcomes among Indian women. I found that the gender inequality expressed as the gendered household practice of seclusion was negatively associated with body weight of Indian women. Further, I found that participation in all household decisions by women of the household was generally not associated with body weight outcomes. The association between gendered household practices and women’s body weight outcomes was generally similar among rural and urban Indian women. In the final essay, I examined whether perinatal food environments (FE), maternal gestational weight gain (GWG) and early childhood weight (ECW) outcomes are associated. I used data on mother-children dyads from the Early Childhood Longitudinal Study – Birth cohort (ECLS-B), Area Resource Files (ARF) and Current Business Practices (CBP). I found that maternal GWG was associated with ECW outcomes. I also found that measures of food environment were associated with ECW outcomes. Specifically, I found that having an additional full-service restaurant per one thousand population in the maternal perinatal county of residence was associated with lower Body Mass Index (BMI) among children at age two years. Finally, I found that GWG did not mediate the association between food environment and ECW outcomes.

A greater understanding of critical periods of body weight regulation, including pregnancy, may aid in efforts to optimize weight management strategies for the mother and her baby. The gestational period has been implicated to play, in the child, a vital role in the developmental origins of obesity and other cardiometabolic diseases later in life. Therefore, we initially examined existing literature on the role of maternal obesity and its link to pediatric obesity and documented the known underlying physiological mechanisms responsible for this relationship while suggesting potential intervention targets that may improve maternal-fetal outcomes. In a second paper, we aimed to quantify maternal predictors of large for gestational age (LGA) neonates in the Ottawa and Kingston (OaK) birth cohort with specific hypotheses verifying the independent contribution of maternal prepregnancy body mass index (BMI) and excessive gestational weight gain (GWG) to fetal overgrowth. This paper also highlights the clinical utility of the revised 2009 Institute of Medicine GWG guidelines and discusses the potential role of physiological factors underlying the observed associations between BMI, excessive GWG and LGA neonates. As a follow-up to our population-level analysis (i.e., OAK cohort), papers three and four highlight how the insulin-like growth factor (IGF) axis, a vital regulator of growth and development, may be compromised at the molecular level in cases of maternal obesity (paper 3) and excessive GWG (paper 4). In paper 3 we show that maternal obesity is associated with attenuated expression of IGF binding protein-4 (IGFBP4) in umbilical cord blood and discuss how this may preferentially promote fetal adipogenesis. The effects of excessive GWG on IGF axis protein expression are addressed in paper four where we show that excessive weight gain during pregnancy is associated with increased expression of IGFBP3 in maternal circulation in normoglycemic term pregnancies. In this paper we discuss the potential inhibitory role of IGFBP3 on adipogenesis and how it relates to glucose intolerance during pregnancy. Recognizing that both obesity and excessive GWG can alter physiological processes in mother and her baby, appropriate evidence-based interventions are warranted to best optimize outcomes. In paper five, we discuss the results of a study which sought to assess patient information channels and knowledge of nutrition and physical activity during pregnancy with the intent that these findings be applied to best design efficacious strategies that cater to the needs of our target group of pregnant women. In our analysis we show that the majority of pregnant women studied would be willing to participate in a lifestyle intervention for their own personal health and that of their child. Of great interest was the observation that most women were not informed of the importance of pregnancy-specific energy intake, or made aware of their own healthy GWG targets. Additionally, many of the respondents reported receiving no information pertaining to appropriate physical activity recommendations; despite the fact that the vast majority of participants consider this lifestyle modality to be safe during their pregnancy. Finally in paper six, we build on the results of our previous work and evaluate the risks and benefits of physical activity during pregnancy on maternal-fetal outcomes through a review of the literature and note that engaging in non-sedentary pursuits during gestation may aid in maternal weight regulation, protect against metabolic disorders and optimize neonatal birth weight and body composition. Overall, the collective nature of the papers presented in this dissertation provides qualitative and quantitative evidence to support not only the complexity of body weight regulation in the mother and her baby, but also highlights potential avenues for intervention that may improve maternal-fetal outcomes during this critical period.

A greater understanding of critical periods of body weight regulation, including pregnancy, may aid in efforts to optimize weight management strategies for the mother and her baby. The gestational period has been implicated to play, in the child, a vital role in the developmental origins of obesity and other cardiometabolic diseases later in life. Therefore, we initially examined existing literature on the role of maternal obesity and its link to pediatric obesity and documented the known underlying physiological mechanisms responsible for this relationship while suggesting potential intervention targets that may improve maternal-fetal outcomes. In a second paper, we aimed to quantify maternal predictors of large for gestational age (LGA) neonates in the Ottawa and Kingston (OaK) birth cohort with specific hypotheses verifying the independent contribution of maternal prepregnancy body mass index (BMI) and excessive gestational weight gain (GWG) to fetal overgrowth. This paper also highlights the clinical utility of the revised 2009 Institute of Medicine GWG guidelines and discusses the potential role of physiological factors underlying the observed associations between BMI, excessive GWG and LGA neonates. As a follow-up to our population-level analysis (i.e., OAK cohort), papers three and four highlight how the insulin-like growth factor (IGF) axis, a vital regulator of growth and development, may be compromised at the molecular level in cases of maternal obesity (paper 3) and excessive GWG (paper 4). In paper 3 we show that maternal obesity is associated with attenuated expression of IGF binding protein-4 (IGFBP4) in umbilical cord blood and discuss how this may preferentially promote fetal adipogenesis. The effects of excessive GWG on IGF axis protein expression are addressed in paper four where we show that excessive weight gain during pregnancy is associated with increased expression of IGFBP3 in maternal circulation in normoglycemic term pregnancies. In this paper we discuss the potential inhibitory role of IGFBP3 on adipogenesis and how it relates to glucose intolerance during pregnancy. Recognizing that both obesity and excessive GWG can alter physiological processes in mother and her baby, appropriate evidence-based interventions are warranted to best optimize outcomes. In paper five, we discuss the results of a study which sought to assess patient information channels and knowledge of nutrition and physical activity during pregnancy with the intent that these findings be applied to best design efficacious strategies that cater to the needs of our target group of pregnant women. In our analysis we show that the majority of pregnant women studied would be willing to participate in a lifestyle intervention for their own personal health and that of their child. Of great interest was the observation that most women were not informed of the importance of pregnancy-specific energy intake, or made aware of their own healthy GWG targets. Additionally, many of the respondents reported receiving no information pertaining to appropriate physical activity recommendations; despite the fact that the vast majority of participants consider this lifestyle modality to be safe during their pregnancy. Finally in paper six, we build on the results of our previous work and evaluate the risks and benefits of physical activity during pregnancy on maternal-fetal outcomes through a review of the literature and note that engaging in non-sedentary pursuits during gestation may aid in maternal weight regulation, protect against metabolic disorders and optimize neonatal birth weight and body composition. Overall, the collective nature of the papers presented in this dissertation provides qualitative and quantitative evidence to support not only the complexity of body weight regulation in the mother and her baby, but also highlights potential avenues for intervention that may improve maternal-fetal outcomes during this critical period.

Made available in DSpace on 2011-05-04T12:42:05Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / O presente estudo teve como principal propósito analisar o estado nutricional de gestantes adolescentes do Município do Rio de Janeiro, identificando características maternas associadas ao desfecho obstétrico peso ao nascer e validando um método para o diagnósticode ganho de peso gestacional. O desenho do estudo foi descritivo do tipo transversal desenvolvido com dados primários obtidos com o Estudo da Morbi-mortalidade e da Atenção Peri e Neonatal no MRJ, 1999-2001. A análise estatística foi dirigida a testar a hipótese de homogeneidade de proporções mediante análises bi e multivariada, com o uso de regressão logística multivariada e sua apresentação dividi-se em três artigos. O primeiro é uma revisão sistemática que visou a identificação de métodos de avaliação nutricional de gestantes adotados no Brasil e sua associação com desfechos obstétricos. / The main purpose of the current study is to analyze the nutritional state of pregnant adolescents in Rio de Janeiro, identifying maternal characteristics associated with the outcome of obstetric birth weight and validating a method for diagnosis of gestational weight gain. The design of the study was descriptive and cross sectional with the primary data obtained from “Study of Morbidity/Mortality and Care in Neonatal and Perinatal in the Municipal of Rio de Janeiro, 1999-2001.” Statistical analysis was aimed at testing the hypothesis of homogeneity of mean ratio by bi- and multivariate analysis – using multivariate logistic regression and its results are presented in this series of three articles. The first is a systematic review aimed at identification of methods of nutritional evaluation of pregnant women utilized in Brazil and its association with obstetric outcomes. There were 26 studies identified using the method recommended by Rosso(1985),the results demonstrate a serious discrepancy of literature, in quantity and quality, that contributes to evaluating the effectiveness of methods of anthropometric assessment of pregnant Brazilian women. The development of studies with methodological rigor in this area is needed and must address age differences as well as biological, socioeconomic and environmental factors of pregnant women. The second article aims to verify the association of maternal characteristics and the obstetric results of gestational weight gain among adolescent mothers in Rio de Janeiro. Included is a subsample of 703 adolescent mothers that carried full term. The results showed an association between the number of prenatal visits and weight gain during pregnancy, as well as an increase in the proportion of excessive weight gain amongst pregnant adolescents, particularly in the youngest adolescents. It concluded that the pre-natal consults improve quantity of weight gain but did not guarantee the quality of this gain, in particular for the younger adolescents. The quality of weight gain could have improved if pre natal nutritional care was valued and the recommendations utilized were geared torwards the specific nutritional standards for adolescents, from the beginning of the pregnancy. The third article assesses the performance of different methods of anthropometric evaluation of pregnant adolescents in predicting birth weight. The study was conducted with a subsample of 826 adolescent mothers. The evaluation of weight gain at the end of their pregnancy was assessed by following the recommendated method of the Institute of Medicine (IOM,1990;92), and adaptations of the MS (2006) following the recommended classification of pre-gestational BMI for adolescents (WHO,1995;2007) Low birth weight was defined as “less than 2500 grams” (WHO, 1995) for children born full term, “below the 10th percentile” for those born at less than 37 weeks of gestation, and a macrosomia as weight equal to or greater than 4000 grams. For small maternal stature a cutoff was used of falling below the 3rd percentile (WHO, 2007). Calculation of SE, E, VPP, VPN and the accuracy of the evaluation of gestational weight gain for the prediction of the BW. Given the growing epidemic of obesity in increasingly early age, the best option for assessment is the anthropometric pre-gestational nutritional method as recommended by WHO (2007), specifically for adolescents. This ensures a prediction of gestational weight gain within the internationally recommended ranges (IOM, 1990;92) and contributes to favorable outcomes, improving future prospects for the mother and child.

A greater understanding of critical periods of body weight regulation, including pregnancy, may aid in efforts to optimize weight management strategies for the mother and her baby. The gestational period has been implicated to play, in the child, a vital role in the developmental origins of obesity and other cardiometabolic diseases later in life. Therefore, we initially examined existing literature on the role of maternal obesity and its link to pediatric obesity and documented the known underlying physiological mechanisms responsible for this relationship while suggesting potential intervention targets that may improve maternal-fetal outcomes. In a second paper, we aimed to quantify maternal predictors of large for gestational age (LGA) neonates in the Ottawa and Kingston (OaK) birth cohort with specific hypotheses verifying the independent contribution of maternal prepregnancy body mass index (BMI) and excessive gestational weight gain (GWG) to fetal overgrowth. This paper also highlights the clinical utility of the revised 2009 Institute of Medicine GWG guidelines and discusses the potential role of physiological factors underlying the observed associations between BMI, excessive GWG and LGA neonates. As a follow-up to our population-level analysis (i.e., OAK cohort), papers three and four highlight how the insulin-like growth factor (IGF) axis, a vital regulator of growth and development, may be compromised at the molecular level in cases of maternal obesity (paper 3) and excessive GWG (paper 4). In paper 3 we show that maternal obesity is associated with attenuated expression of IGF binding protein-4 (IGFBP4) in umbilical cord blood and discuss how this may preferentially promote fetal adipogenesis. The effects of excessive GWG on IGF axis protein expression are addressed in paper four where we show that excessive weight gain during pregnancy is associated with increased expression of IGFBP3 in maternal circulation in normoglycemic term pregnancies. In this paper we discuss the potential inhibitory role of IGFBP3 on adipogenesis and how it relates to glucose intolerance during pregnancy. Recognizing that both obesity and excessive GWG can alter physiological processes in mother and her baby, appropriate evidence-based interventions are warranted to best optimize outcomes. In paper five, we discuss the results of a study which sought to assess patient information channels and knowledge of nutrition and physical activity during pregnancy with the intent that these findings be applied to best design efficacious strategies that cater to the needs of our target group of pregnant women. In our analysis we show that the majority of pregnant women studied would be willing to participate in a lifestyle intervention for their own personal health and that of their child. Of great interest was the observation that most women were not informed of the importance of pregnancy-specific energy intake, or made aware of their own healthy GWG targets. Additionally, many of the respondents reported receiving no information pertaining to appropriate physical activity recommendations; despite the fact that the vast majority of participants consider this lifestyle modality to be safe during their pregnancy. Finally in paper six, we build on the results of our previous work and evaluate the risks and benefits of physical activity during pregnancy on maternal-fetal outcomes through a review of the literature and note that engaging in non-sedentary pursuits during gestation may aid in maternal weight regulation, protect against metabolic disorders and optimize neonatal birth weight and body composition. Overall, the collective nature of the papers presented in this dissertation provides qualitative and quantitative evidence to support not only the complexity of body weight regulation in the mother and her baby, but also highlights potential avenues for intervention that may improve maternal-fetal outcomes during this critical period.