Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study.

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.

Monitoring for micronutrient deficiency after bariatric surgery-what is the risk?

BACKGROUND: Bariatric surgery may increase the risk of micronutrient deficiencies; however, confounders including preoperative deficiency, supplementation and inflammation are rarely considered. OBJECTIVE: To examine the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. SETTING: Two public hospitals, Australia. METHODS: Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at 1-3, 6 and 12 months after gastric bypass (GB; Roux-en-Y Gastric Bypass and Single Anastomosis Gastric Bypass; N = 66) or sleeve gastrectomy (SG; N = 144). Participant retention at 12 months was 81%. RESULTS: Pre-operative micronutrient deficiency was common, for vitamin D (29-30%), iron (13-22%) and selenium (39% GB cohort). Supplement intake increased after surgery; however, dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at 6 months (OR 13 [95% CI 2, 84]; p = 0.007), with folic acid supplementation being independently associated with reduced risk. Within 1-3 months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p < 0.01), vitamin A (21% vs. 3%, p < 0.01) and selenium (59% vs. 39%, p < 0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only. CONCLUSION: In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency. Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted.

Survey of Australian clinicians' antenatal care and management practices in pregnant women with a history of bariatric surgery.

Background: Pregnancy following bariatric surgery requires tailored care. The current Australian care provision and its alignment with consensus guidelines is unclear. Methods: Antenatal care clinicians were invited to complete a web-based survey assessing multidisciplinary referral, gestational diabetes mellitus (GDM) and micronutrient management practices. Results: Respondents (n = 100) cared for pregnant women with a history of bariatric surgery at least monthly (63%) with most (54%) not using a specific guideline to direct care. GDM screening methods included one-week of home blood glucose monitoring (43%) or the oral glucose tolerance test (42%). Pregnancy multivitamin supplementation changes (59%) with bariatric surgery type were common. Half (54%) screened for micronutrient deficiencies every trimester and conducted additional growth ultrasounds (50%). Conclusion: The care clinicians report providing may not align with current international consensus guidelines. Further studies with increased obstetric clinician response may aid increased understanding of current practices. The development of workplace management guidelines for pregnancy in women with a history of bariatric surgery may assist with providing consistent evidence-based care.

A Systematic Review Investigating Maternal Nutrition During Pregnancy After Bariatric Surgery.

The aim of this review was to report on maternal diet, micronutrient supplementation, and gestational weight gain (GWG) during pregnancy following bariatric surgery and explore the impact on maternal micronutrient deficiency, offspring growth, and perinatal outcomes. A search in PubMed, CINAHL, EMBASE, and ProQuest in July 2022 returned 23 eligible studies (n = 30-20, 213). Diet was reported in two studies, supplementation in six and GWG in 19 studies. Although many women did not achieve healthy GWG, no consistent link with adverse outcomes was reported. Studies were grades II and III on the National Health and Medical Research Council evidence hierarchy and received a neutral or negative score on the Academy of Nutrition and Dietetics Quality Criteria Checklist, suggesting that methodological limitations impact the reliability of reported findings.

Patient experiences with micronutrient and overall nutrition management after bariatric surgery: identifying facilitators and barriers to implementing care.

BACKGROUND: Adherence to perioperative guideline recommendations for prophylactic supplementation and regular biochemical monitoring is suboptimal. However, little is known about the patient perspective on this postoperative challenge. OBJECTIVES: To qualitatively explore patient experiences of postoperative micronutrient management and identify patient-reported barriers and facilitators to the provision of nutrition care. SETTING: Two tertiary public hospitals in Queensland, Australia. METHODS: Semi-structured interviews were conducted with 31 participants 12 months after bariatric surgery. Inductive analysis of interview transcripts was performed using applied thematic analysis, and deductive analysis was performed by aligning interview themes against the Theoretical Domains Framework and the Capability, Motivation, and Opportunity Behavior Change Wheel Framework. RESULTS: Participants' perceptions of engagement with the bariatric surgery multidisciplinary team greatly influenced their experience with overall nutrition care, including but not exclusive to micronutrient care. At times, this engagement negatively impacted patients' experiences with their nutrition care and related to varied acceptance of healthcare advice from the team or, at times, an unmet desire for person-centered communication styles. Engaging person-centered care techniques had a positive influence on patient experience with micronutrient and overall nutrition care. Micronutrient management (taking supplements and having regular blood tests) was broadly accepted and enabled by the presence of established medication and blood test routines preoperatively. However, challenges did exist and were practical in nature. Incorporating education on habit-forming techniques was identified as a facilitator to assist with micronutrient management. CONCLUSION: Although participants mostly accept embedding micronutrient management into their life, developing interventions that focus on habit-forming skills and that enable multidisciplinary teams to provide person-centered care is recommended to enhance care after surgery.

Midwife-Led Continuity of Antenatal Care and Breastfeeding Duration Beyond Postpartum Hospital Discharge: A Systematic Review.

BACKGROUND: The World Health Organization recommends that infants should be exclusively breastfed for the first 6 months of life and that breastfeeding should continue for 2 years and beyond. Most women initiate breastfeeding, but many do not continue for the recommended duration. While midwife-led continuity of antenatal care is linked to improved mother and infant outcomes, the influence on breastfeeding duration has not been previously reviewed. RESEARCH AIM: To critically analyze the literature that compared midwife-led continuity of antenatal care with other models of care where researchers have measured breastfeeding duration beyond postpartum hospital discharge. METHODS: A systematic literature review with critical analysis was used to answer the research aim. We systematically searched and screened five databases for quantitative studies where researchers had reported breastfeeding duration beyond postpartum hospital discharge after midwife-led continuity of antenatal care, compared with another model of antenatal care. Methodological quality was assessed using tools from the Cochrane Collaboration (RoB2 and ROBINS-I). In total, nine studies met the inclusion criteria. RESULTS: Clear conclusions about the association between midwife-led continuity of antenatal care and breastfeeding duration were not found. The risk of bias within non-randomized studies ranged from serious to critical, and a judgement of "some concerns" of risk of bias in the one randomized study. CONCLUSION: To date, the question of whether midwife-led continuity of antenatal care improves breastfeeding duration has not been established. There has been a lack of consistency in definitions of breastfeeding and descriptions of models of care, which has weakened the evidence-based of literature reviewed.Our review protocol was registered with PROSPERO; although due to COVID-19, this registration was not checked for eligibility by the PROSPERO team (CRD42020151276). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151276.

An implementation science approach for developing and implementing a dietitian-led model of care for gestational diabetes: a pre-post study.

BACKGROUND: There is strong evidence that women with gestational diabetes mellitus (GDM) who receive a minimum of three appointments with a dietitian may require medication less often. The aim of this study was to evaluate the impact of a dietitian-led model of care on clinical outcomes and to understand the utility of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework as a prospective tool for implementation. METHODS: This was a pre-post intervention study measuring outcomes before-and-after changing a gestational diabetes (GDM) model of care and included women with GDM managed at a large, regional hospital in Queensland, Australia. The i-PARIHS framework was used to develop, implement and evaluate a dietitian-led model of care which increased dietetic input for women with GDM to a minimum of one initial education and two review appointments. The outcomes were adherence to the schedule of appointments, clinician perspective of the implementation process, pharmacotherapy use, gestational age at commencement of pharmacotherapy and birth weight. Pre- and post- comparisons of outcomes were made using t-tests and chi-squared tests. RESULTS: Adherence to the dietetic schedule of appointments was significantly increased from 29 to 82% (p < 0.001) but pharmacotherapy use also increased by 10% (p = 0.10). There were significantly more women in the post-intervention group who were diagnosed with GDM prior to 24 weeks gestation, a strong independent predictor of pharmacotherapy use. Infant birthweight remained unchanged. The i-PARIHS framework was used as a diagnostic tool and checklist in the model of care development phase; a facilitation tool during the implementation phase; and during the evaluation phase was used as a reflection tool to identify how the i-PARIHS constructs and their interactions that may have impacted on clinical outcomes. CONCLUSIONS: The i-PARIHS framework was found to be useful in the development, implementation and evaluation of a dietitian-led model of care which saw almost 90% of women with GDM meet the minimum schedule of dietetic appointments.

Midwife readiness to provide woman-centred weight gain support: Exploring perspectives across models of care.

PROBLEM: More than half of women start pregnancy above a healthy weight and two-thirds gain excess weight during pregnancy, increasing the risk of complications. BACKGROUND: Little research has examined the influence model of care has on weight-related outcomes in pregnancy. AIM: To explore how continuity vs non-continuity models of midwifery care influence perceived readiness to provide woman-centred interventions with women supporting pregnancy weight gain, healthy eating and physical activity. METHODS: Focus groups were conducted with midwives working in either continuity or non-continuity models of care at a tertiary hospital in Queensland, Australia. Focus group questions elicited elements around practices, the healthcare environment and woman-centred care skills. Findings were analysed using the Framework Approach to qualitative research. FINDINGS: Four focus groups, involving 15 participants from the continuity of care model and 53 from the non-continuity model, were conducted. Continuity of care participants reported greater readiness to provide woman-centred interventions than those from non-continuity models. Barriers faced by both groups included gaps in communication training, education resources and multidisciplinary support. DISCUSSION: Midwives across models of care require greater support in this area, in particular training in communication and better multidisciplinary service integration to support women. CONCLUSION: The care model appears to influence capacity to deliver person/woman-centred interventions, highlighting the need for tailored training for the healthcare setting. The roles of other health professionals in delivering weight management interventions during pregnancy also need to be examined.

Searching for Utopia, the Challenge of Standardized Medical Nutrition Therapy Prescription in Gestational Diabetes Mellitus Management: A Critical Review.

Gestational diabetes mellitus (GDM) is a common pregnancy disorder and the incidence is increasing worldwide. GDM is associated with adverse maternal outcomes which may be reduced with proper management. Lifestyle modification in the form of medical nutrition therapy and physical activity, as well as self-monitoring of blood glucose levels, is the cornerstone of GDM management. Inevitably, the search for the "ultimate" diet prescription has been ongoing. Identifying the amount and type of carbohydrate to maintain blood glucose levels below targets while balancing the nutritional requirements of pregnancy and achieving gestational weight gain within recommendations is challenging. Recent developments in the area of the gut microbiota and its impact on glycemic response add another layer of complexity to the success of medical nutrition therapy. This review critically explores the challenges to dietary prescription for GDM and why utopia may never be found.

Impact of service-wide initiatives to support healthy pregnancy weight gain on weight-related documentation.

BACKGROUND: Excess gestational weight gain is associated with adverse pregnancy outcomes. Addressing barriers to the provision of best practice care that supports healthy pregnancy weight gain could assist staff in clinical care; however, little is known about changes to staff practices after ameliorating barriers. AIMS: To evaluate if service initiatives to promote healthy pregnancy weight gain improve weight-related documentation by antenatal staff throughout pregnancy care. MATERIALS AND METHODS: Service initiatives including staff training, familiarisation with a pregnancy weight gain chart and placement of scales in clinic rooms were introduced. Pregnancy health records were audited for deliveries pre- (2014) and post-implementation (2017) to obtain weight-related measures. Measures assessed included the documentation of pre-pregnancy weight, height, pre-pregnancy body mass index (BMI), referral to dietetic services (if overweight) and the accuracy of pre-pregnancy BMI calculation. The proportion of visits with weight recorded during pregnancy was also audited. RESULTS: A total of 1003 and 1050 records were included from the pre- and post-intervention groups respectively. Significant improvements over time were observed in the documentation of pre-pregnancy weight (P < 0.001), BMI (P < 0.001), accuracy of BMI calculation (P < 0.001) and for obese women proportion of visits with weight recorded (P = 0.02). There was a non-significant increase in the documentation of dietetic referral for overweight women (1.1% vs 2.2%, P = 0.27) and proportion of visits with weight recorded for women across all pre-pregnancy BMI groups (49% vs 51%, P = 0.07). CONCLUSIONS: Addressing barriers to supporting healthy pregnancy weight gain through service-wide initiatives may improve weight-related documentation by antenatal staff.

Guidelines for review of patients on haemodialysis: Are we meeting patient needs?

AIM: This study aimed to determine satisfaction with dietetic services, identify barriers and enablers to engaging with dietetic services and acceptable methods of delivering nutrition care to patients on haemodialysis. METHODS: A questionnaire was developed based on existing satisfaction surveys and key constructs from the Theoretical Domains Framework to understand patient behaviours around accessing dietetic services. Constructs were grouped according to the COM-B model (Capability, Opportunity and Motivation) of the Behaviour Change Wheel to inform future interventions. Patients at three Brisbane haemodialysis units participated, with questionnaire administered via laptop (by dietetic assistants) or paper-based version (by nurses). RESULTS: Sixty-six patients completed the questionnaire (response rate 40%, 62 ± 14 years, 58% male). Most respondents (n = 63, 95%) reported seeing a dietitian since commencing haemodialysis. A quarter of respondents reported declining or not wanting to see the dietitian. Despite this, questions pertaining to service satisfaction were largely positive. Questions related to enablers and barriers to engaging with the dietitian revealed the domain of motivation as the main barrier with 41% (n = 26) participants not wanting to make dietary changes. The domains of capability and opportunity were not barriers. Patients preferred receiving nutrition information from dietitians, when they had a question or concern, rather than at predefined intervals. Telehealth was not acceptable to the majority of participants. CONCLUSIONS: While patients were satisfied with dietetic care, their preferences for dietetic service delivery were not aligned with current evidence-based guidelines, highlighting need for alternative models of care. Dietetic interventions need to be delivered in a way that addresses motivation.

Does Bariatric Surgery Cause Vitamin A, B1, C or E Deficiency? A Systematic Review.

BACKGROUND: The restrictive and/or malabsorptive nature of bariatric surgery may increase the risk for micronutrient deficiencies. This systematic review aimed to identify and critique the evidence for vitamin A, B1, C or E deficiencies associated with bariatric surgery. METHODS: This review utilised PRISMA and MOOSE frameworks with NHMRC evidence hierarchy and the American Dietetic Association bias tool to assess the quality of articles. RESULTS: Twenty-one articles were included and once critiqued all studies were of level IV grade and neutral or negative in quality. The relevance of measuring micronutrient supplementation and inflammatory markers for validity of serum vitamins is absent within the literature. CONCLUSIONS: Future research is needed to investigate the risk of deficiency for these procedures with focus on confounders to serum micronutrients.

Supporting healthy weight gain and management in pregnancy: Does a mandatory training education session improve knowledge and confidence of midwives?

OBJECTIVE: To examine if a brief midwifery education and training session incorporated into annual mandatory training improves the knowledge and confidence of midwives to support healthy weight gain and management in pregnancy. DESIGN: An implementation evaluation using a pre-post study design was used. Midwives completed a self- administered questionnaire prior to and following completion of the training session. Objective knowledge, perceived knowledge and confidence in relation to nutrition, physical activity and healthy weight gain and management, and process measures related to the training were assessed. PARTICIPANTS AND SETTING: All midwives from a tertiary birthing hospital in Brisbane Australia who attended the annual mandatory training day in 2015 were invited to participate. MEASUREMENT AND FINDINGS: Of the 270 midwives who attended the training 154 pre and 114 post training questionnaires were returned. An increase in perceived knowledge across topic areas was reported by 70-97% of respondents, while perceived confidence increased for 83-91% of respondents across each topic area. Objective knowledge score increased from 11 pre-training to 15 post training (maximum score 17) (p < 0.001). Ninety six percent of respondents agreed the training provided practical communication strategies and 100% would recommend the training to others. KEY CONCLUSIONS: This brief education session integrated into an existing mandatory training program, improved the knowledge and confidence of midwives in delivering advice and support for healthy pregnancy weight gain. IMPLICATIONS FOR PRACTICE: This improvement is the first step in changing practice to prevent excess weight gain during the antenatal period. This program offers an innovative model to support midwives implement change across other health services. A low cost intervention that was well received by midwives can address identified barriers to the provision of best practice care that supports a healthy pregnancy weight gain in a sustainable forum.