The use of whole body calorimetry to compare measured versus predicted energy expenditure in postpartum women.

BACKGROUND: Accurate assessment of energy expenditure may support weight-management recommendations. Measuring energy expenditure for each postpartum woman is unfeasible; therefore, accurate predictive equations are needed. OBJECTIVES: This study compared measured with predicted resting energy expenditure (REE) and total energy expenditure (TEE) in postpartum women. METHODS: This was a longitudinal observational study. REE was measured at 3 mo postpartum (n = 52) and 9 mo postpartum (n = 49), whereas TEE was measured once at 9 mo postpartum (n = 43) by whole body calorimetry (WBC). Measured REE (REEWBC) was compared with 17 predictive equations; measured TEE plus breast milk energy output (ERWBC) was compared with the estimated energy requirements/Dietary Reference Intakes equation (EERDRI). Fat and fat-free mass were measured by dual-energy X-ray absorptiometry. Group-level agreement was assessed by the Pearson correlation, paired t test, and Bland-Altman (bias) analyses. Individual-level accuracy was assessed with the use of Bland-Altman limits of agreement, and by the percentage of women with predicted energy expenditure within 10% of measured values ("accuracy"). RESULTS: The cohort was primarily Caucasian (90%). At a group level, the best equation predicting REEWBC was the DRI at 3 mo postpartum (-7 kcal, -0.1%; absolute and percentage bias, respectively), and the Harris-Benedict at 9 mo postpartum (-17 kcal, -0.5%). At an individual level, the Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU) height and weight equation was the most accurate at 3 mo postpartum (100% accuracy) and 9 mo postpartum (98% accuracy), with the smallest limits of agreement. Equations including body composition variables were not more accurate. Compared with ERWBC, EERDRI bias was -36 kcal, with inaccurate predictions in 33% of women. CONCLUSIONS: Many REE predictive equations were accurate for group assessment, with the FAO/WHO/UNU height and weight equation having the highest accuracy for individuals. EERDRI performed well at a group level, but inaccurately for 33% of women. A greater understanding of the physiology driving energy expenditure in the postpartum period is needed to better predict TEE and ultimately guide effective weight-management recommendations.

Healthcare providers' gestational weight gain counselling practises and the influence of knowledge and attitudes: a cross-sectional mixed methods study.

OBJECTIVE: To understand current gestational weight gain (GWG) counselling practices of healthcare providers, and the relationships between practices, knowledge and attitudes. DESIGN: Concurrent mixed methods with data integration: cross-sectional survey and semistructured interviews. PARTICIPANTS: Prenatal healthcare providers in Canada: general practitioners, obstetricians, midwives, nurse practitioners and registered nurses in primary care settings. RESULTS: Typically, GWG information was provided early in pregnancy, but not discussed again unless there was a concern. Few routinely provided women with individualised GWG advice (21%), rate of GWG (16%) or discussed the risks of inappropriate GWG to mother and baby (20% and 19%). More routinely discussed physical activity (46%) and food requirements (28%); midwives did these two activities more frequently than all other disciplines (P<0.001). Midwives interviewed noted a focus on overall wellness instead of weight, and had longer appointment times which allowed them to provide more in-depth counselling. Regression results identified that the higher priority level that healthcare providers place on GWG, the more likely they were to report providing GWG advice and discussing risks of GWG outside recommendations (ß=0.71, P<0.001) and discussing physical activity and food requirements (ß=0.341, P<0.001). Interview data linked the priority level of GWG to length of appointments, financial compensation methods for healthcare providers and the midwifery versus medical model of care. CONCLUSIONS: Interventions for healthcare providers to enhance GWG counselling practices should consider the range of factors that influence the priority level healthcare providers place on GWG counselling.

Qualitative Assessment of Key Messages about Nutrition and Weight Gain in Pregnancy in Printed Educational Materials in Alberta.

Printed educational materials are a common source of health information, although their effectiveness in improving women's knowledge or self-care in pregnancy has been questioned. This study describes the information in printed educational materials that address healthy eating during pregnancy and gestational weight gain (GWG) that are currently used in Alberta, Canada. Content of 6 resources was analyzed using a constant comparison qualitative approach. Resources emphasized healthy eating, prenatal supplements, folate supplementation, and healthy weight gain. More resources discussed the importance of "eating enough" than provided guidance on avoiding excessive GWG. Themes identified were: "everything is important" meaning that all healthy behaviours are important, making prioritization difficult; "more is more" emphasized eating more over moderation; "everyone is individual" suggests women seek individualized care through the care provider; and "contradictions" describes differences in content and recommendations within and between resources. New or revised versions of resources should provide congruent information with up-to-date recommendations that are easily prioritized. Care providers should be aware of contradictory information or information that does not align with current recommendations within printed educational materials and be ready to help women address the areas important for her personal behaviour change.

Relations between neighbourhood socioeconomic status and birth outcomes are mediated by maternal weight.

Lower neighbourhood-level socioeconomic status (SES) has been repeatedly associated with an increased risk of adverse birth outcomes, even after controlling for individual-level SES. Few studies have empirically assessed potential mechanisms underlying the associations. The objectives of this study were to (1) examine relations between neighbourhood SES and birth outcomes, and (2) explore if maternal weight variables mediated these relations. Data came from a provincial prospective pregnancy cohort study in Canada. Census data was used to create a continuous measure of neighbourhood SES. Using information from maternal questionnaires and medical records, two mediators (pre-pregnancy body mass index (BMI), and gestational weight gain (GWG)) and five birth outcomes (preterm birth, low birth weight, macrosomia, small for gestational age (SGA), large for gestational age (LGA)) were examined. After adjusting for individual-level covariates, mediation analyses supported significant associations between lower neighbourhood SES and increased risk of macrosomia (b = 0.1183, 95% BCa CI: 0.0607-0.1896) and LGA (b = 0.0565, 95% BCa CI: 0.0040-0.1186) through higher pre-pregnancy BMI. Significant associations were also observed between neighbourhood SES and macrosomia, LGA, and preterm birth (b = 0.0105, 95% BCa CI: 0.0014-0.0246) through pre-pregnancy BMI and GWG in tandem; pairwise comparisons suggested that associations with macrosomia and LGA through pre-pregnancy BMI alone were significant over associations through pre-pregnancy BMI and GWG together. These findings add to a growing body of literature assessing potential mechanisms underlying relations between neighbourhood SES and adverse birth outcomes, and suggest that neighbourhood-level SES may influence birth outcomes through maternal weight.

Dietary assessment is a critical element of health research - Perspective from the Partnership for Advancing Nutritional and Dietary Assessment in Canada.

Challenges and complexities associated with assessing dietary intakes are numerous, but not insurmountable. This opinion paper from Canadian researchers draws attention to the importance of building capacity and providing funding opportunities for research in dietary assessment methods in Canada and elsewhere. Such strategies would contribute to a better understanding of the roles played by diet in human health and better translation of this information into the most meaningful and effective dietary guidelines, policies, and interventions.

Kikiskawâwasow - prenatal healthcare provider perceptions of effective care for First Nations women: an ethnographic community-based participatory research study.

BACKGROUND: Pregnant Indigenous women suffer a disproportionate burden of risk and adverse outcomes relative to non-Indigenous women. Although there has been a call for improved prenatal care, examples are scarce. Therefore, we explored the characteristics of effective care with First Nations women from the perspective of prenatal healthcare providers (HCPs). METHODS: We conducted an ethnographic community-based participatory research study in collaboration with a large Cree First Nations community in Alberta, Canada. We carried out semi-structured interviews with 12 prenatal healthcare providers (HCPs) that were recorded, transcribed, and subjected to qualitative content analysis. RESULTS: According to the participants, relationships and trust, cultural understanding, and context-specific care were key features of effective prenatal care and challenge the typical healthcare model. HCPs that are able to foster sincere, non-judgmental, and enjoyable interactions with patients may be more effective in treating pregnant First Nations women, and better able to express empathy and understanding. Ongoing HCP cultural understanding specific to the community served is crucial to trusting relationships, and arises from real experiences and learning from patients over and above relying only on formal cultural sensitivity training. Consequently, HCPs report being better able to adapt a more flexible, all-inclusive, and accessible approach that meets specific needs of patients. CONCLUSIONS: Aligned with the recommendations of the Truth and Reconciliation Commission of Canada, improving prenatal care for First Nations women needs to allow for genuine relationship building with patients, with enhanced and authentic cultural understanding by HCPs, and care approaches tailored to women's needs, culture, and context.

Contrasting "back home" and "here": how Northeast African migrant women perceive and experience health during pregnancy and postpartum in Canada.

BACKGROUND: International migration and the number of migrant women who experience pregnancy and childbirth in receiving countries have significantly increased in the last two decades. Migrant women often have unmet social and economic needs during pregnancy, and are more likely to have problems unaddressed by health care systems. In this qualitative study, we explored migrant women's perceptions and experiences of health during pregnancy and postpartum, while participating in a perinatal program offered through a community-based organization. Additionally, we examined sociocultural factors that might have shaped women's health upon migration to the Canadian city of Edmonton, Alberta. METHODS: A community-based participatory research approach was used to engage migrant women connected to a community-based perinatal program in Edmonton. A focused ethnography was conducted with four Northeast African communities (Eritrean, Ethiopian, Oromo and Somali), and involved 10 focus groups with women (n = 8, per group) and direct observations of weekly perinatal program activities. Data generation and analysis occurred concurrently, and all generated data were analyzed using qualitative content analysis to inductively derive codes and categories. RESULTS: Women expressed their perceptions and experiences of health during pregnancy and postpartum by contrasting their countries of origin with Canada, respectively identified as "back home" and "here". Differences in social support and the physical environment (both natural and built) between "back home" and "here" were commonly described as factors that shaped their opportunities to eat healthy, be physically active and emotionally well before and after having a baby "here". Overall, women described that in Canada they lacked the social and environmental factors perceived as key enablers of healthy pregnancies and postpartum. CONCLUSION: A complex network of factors seem to influence Northeast African women's health during pregnancy and postpartum upon migration to Canada. It is of the utmost importance to provide these women with the immediate sociocultural and environmental factors they need to successfully thrive during pregnancy and postpartum, especially while establishing social and support networks "here".

Assessment of Pre-Pregnancy Dietary Intake with a Food Frequency Questionnaire in Alberta Women.

PURPOSE: Pre-pregnancy is an under-examined and potentially important time to optimize dietary intake to support fetal growth and development as well as maternal health. The purpose of the study was to determine the extent to which dietary intake reported by non-pregnant women is similar to pre-pregnancy dietary intake reported by pregnant women using the same assessment tool. METHODS: The self-administered, semi-quantitative food frequency questionnaire (FFQ) was adapted from the Canadian version of the Diet History Questionnaire, originally developed by the National Cancer Institute in the United States. Pregnant women (n = 98) completed the FFQ which assessed dietary intake for the year prior to pregnancy. Non-pregnant women (n = 103) completed the same FFQ which assessed dietary intake for the previous year. Energy, macronutrients, and key micronutrients: long-chain omega-3 fatty acids, folate, vitamin B6, vitamin B12, calcium, vitamin D and iron were examined. RESULTS: Dietary intake between groups; reported with the FFQ; was similar except for saturated fat; trans fat; calcium; and alcohol. Pregnant women reported significantly higher intakes of saturated fat; trans fat; and calcium and lower intake of alcohol in the year prior to pregnancy compared to non-pregnant women who reported intake in the previous year. CONCLUSIONS: Despite limitations; a FFQ may be used to assist with retrospective assessment of pre-pregnancy dietary intake.

The Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study: rationale and methods.

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Predictors of exclusive breastfeeding: observations from the Alberta pregnancy outcomes and nutrition (APrON) study.

BACKGROUND: Despite growing evidence that supports the importance of 6-month exclusive breastfeeding, few Canadian mothers adhere to this, and early weaning onto solids is a common practice. This study assessed infant feeding transitions during the first 6 months postpartum and factors that predicted exclusive breastfeeding to 3 and 6 months. METHODS: This prospective cohort study was part of the Alberta Pregnancy Outcomes and Nutrition study (APrON). From an initial sample of 600 pregnant women recruited from Edmonton and Calgary, 402 mothers provided complete details at 3 months postpartum; 300 stayed on to provide information at 6 months postpartum. During pregnancy and at 3 and 6 months postpartum, data on maternal and infant socio-demographic, behavior, and feeding were collected. RESULTS: Even though there was a high rate of "ever having breastfed" (98.6%), exclusive breastfeeding rates for 3 and 6 months were 54.0% and 15.3%, respectively. After controlling for potential confounders, the study showed that mothers who held post-graduate university degrees were 3.76 times more likely to breastfeed exclusively for 6 months than those without a university degree (95% CI: 1.30-10.92; p = 0.015). In addition, mother of previous children were more likely to breastfeed exclusively for 6 months (OR: 2.21, 95% CI: 1.08-4.52; p = 0.031). Mothers who were in the highest quartile of the Iowa Infant Feeding Attitude Score were 4.29 and 5.40 times more likely to breastfeed exclusively for 3 months (95% CI: 1.31-14.08; p-trend < 0.001) and 6 months (95% CI: 2.75-10.60; P-trend < 0.001), respectively. CONCLUSIONS: The 6-month exclusive breastfeeding rate in Alberta is considerably below national and international breastfeeding recommendations. Professional advice that focuses on prenatal maternal knowledge, attitudes, and misperceptions may promote adherence to World Health Organization breastfeeding guidelines. Knowing that exclusive breastfeeding is less likely to take place among lower-educated, primiparous women may help health practitioners focus their support and education for this group.

Assessment of the mechanisms exerting glucose-lowering effects of dried peas in glucose-intolerant rats.

The present study compared the effects of feeding uncooked pea fractions (embryo v. seed coat) on glucose homeostasis in glucose-intolerant rats and examined potential mechanisms influencing glucose homeostasis. Rats were made glucose intolerant by high-fat feeding, after which diets containing both high-fat and pea fractions were fed for 4 weeks. Rats fed diets containing uncooked pea seed coats low (non-coloured seed coat; NSC) or high (coloured seed coat; CSC) in proanthocyanidins but not embryos had improved oral glucose tolerance (P < 0·05). NSC also lowered fasting and glucose-stimulated insulin secretion (P < 0·05), decreased ß-cell mass by 50 % (P < 0·05) and lowered levels of malondialdehyde, a marker of oxidative stress. Furthermore, NSC decreased the mucosal thickness of the colon by 25 % (P < 0·05), which might affect fibre fermentation and other gut functions. Small but statistically significant (P < 0·05) effects consistent with enhanced glucose transport or metabolism were observed in the skeletal muscle of rats fed NSC or CSC, for example, increased levels of AMP-dependent kinase or akt. We conclude that pea seed coats are the fraction exerting beneficial effects on glucose tolerance. Most of the changes were small in amplitude, suggesting that additive effects on multiple tissues may be important. NSC content appeared to have the most beneficial effects in improving glucose homeostasis but our ability to detect the effect of flavonoids may have been limited by their low concentration in the diet.

How many steps/day are enough? For older adults and special populations.

Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore this review was conducted to translate public health recommendations in terms of steps/day. Normative data indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800 steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively. There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time. However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding) value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to truly translate public health guidelines, these steps should be taken over and above activities performed in the course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately 7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect whole-day estimates of recommended physical activity.

Assessment of Canadian Cree infants' birth size using the WHO Child Growth Standards.

OBJECTIVES: The WHO Child Growth Standards (CGS) which were recently adopted by the Canadian Pediatric Society were used to assess the relative size of Cree newborns. METHODS: Birth weight, length, and head circumference, and growth indices of 2,127 Cree newborns were compared with the CGS. Maternal characteristics of pregnancy and infant birth outcomes were recorded and stratified by birth weight category. RESULTS: Among Cree newborns, 2.4% were low birth weight (LBW) (<2,500 g) and 36.5% were high birth weight (≥4,000 g). The median birth weight (g) for Cree male (4,030) and female (3,900) term newborns was higher than for male (3,346) and female (3,232) newborns of the CGS. Fewer than 1.5% of Cree infants had z-scores <-2SD from the WHO CGS median for BMI-for-age, length-for-age, weight-for-age, or head circumference-for-age whereas 4.6, 7.8, and 23.4% percent had z-scores >+2SD from the WHO CGS median for weight-for-length-for-age, BMI-for-age and head circumference-for-age, respectively. The majority (53.4%) of pregnancies was complicated by obesity and 10.3% were complicated by gestational diabetes mellitus (GDM). Infants weighing 4,000-4,499 g had a comparable prevalence of operative delivery (15.4%) as infants weighing 2,500-3,999 g (13.7%). Infants weighing ≥4,500 g had the highest prevalence of birth injuries (14.0%) and being born to women whose pregnancies were complicated by GDM (20%). CONCLUSIONS: Cree newborns were larger than newborns of the CGS. The appropriateness for Cree infants of defining low and high birth weight from the WHO CGS is uncertain and may lead to inaccurate prognosis of postnatal health.

Effectiveness of the First step Program delivered by professionals versus peers.

BACKGROUND: To compare the effectiveness of a theory-based lifestyle physical activity (PA) program delivered to individuals with type 2 diabetes in diabetes education centers by professionals and peers. METHODS: Changes over 16 weeks in PA (steps/day) and related variables (weight, waist girth, resting heart rate, systolic and diastolic blood pressures) were compared (RMANOVA) for two groups: 157 participants led by 13 different professionals versus 63 participants led by 5 peer leaders. RESULTS: Overall, the 81 male and 139 female participants (age = 55.7 +/- 7.3 years, BMI = 35.2 +/- 6.6) showed an incremental change of 4,059 +/- 3,563 steps/day, which translates into an extra 37 minutes of daily walking (P < .001). Statistically significant improvements were also seen in weight, waist girth, and blood pressure (all P < .001) and resting heart rate (P < .05). There were no significant differences in outcomes between professional and peer-led groups. CONCLUSIONS: A theory-based behavior modification program featuring simple feedback and monitoring tools, and with a proven element of flexibility in delivery, can be effective under real-world conditions while addressing inevitable concerns about resource allocation. Program delivery by peer leaders, in particular, could address a potential obstacle to dissemination by helping to alleviate existing high caseload demands on diabetes educators.