Erica K. Berggren

Preconception care has the potential for a high return on investment

medical intervention with a high return on investment women with chronic illness are significantly more likely to A (ROI) means that the health benefits gained by investment in the intervention compare favorably to its cost. In this issue of the American Journal of Obstetrics & Gynecology, Dr Peterson and colleagues report the substantial health and cost burdens associated with pregestational diabetes (PGDM) that could be prevented with universal preconception care (PCC). The authors estimated the number of preterm births, birth defects, and perinatal deaths that could be reduced by the provision of PCC. Associated discounted lifetime costs averted for the affected cohort of children could be as high as

Variations in resting energy expenditure: impact on gestational weight gain

4.3 billion dollars. Including women with undiagnosed PGDM confers additional benefit in health outcomes and

First Trimester Maternal Glycated Hemoglobin and Sex Hormone–Binding Globulin Do Not Predict Third Trimester Glucose Intolerance of Pregnancy

1.2 billion dollars in averted cost. Although impressive, the authors acknowledge that some of these advantages are already being realized, as some women with PGDM are receiving PCC. Although there is also no consideration for what PCC costs and how it will be provided, we believe that the findings suggest PCC has a high ROI for women with PGDM. Thirty plus years of data demonstrate that improving maternal preconception health improves reproductive health outcomes and may reduce societal costs. For example, a systematic review and metaanalysis found that PCC reduces congenital malformations (relative risk [RR], 0.25; 95% confidence interval [CI], 0.15e0.42), preterm delivery (RR, 0.70; 95% CI, 0.55e0.90) and perinatal mortality (RR, 0.35; 95% CI, 0.15e0.82) among women with PGDM. Targeting women with PGDM before pregnancy allows for optimal glucose control in anticipation of pregnancy and organogenesis. To turn data into action, in 2006 the Centers for Disease Control identified PGDM as a high priority area for PCC, given the known teratogenic effect of hyperglycemia seen in untreated or poorly controlled PGDM. However, provision of universal PCC implies that pregnancy is intended or planned. Almost half of all pregnancies are not planned or are unintended, and unfortunately

Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain

BACKGROUND: There are significant variations in gestational weight gain, with many women gaining in excess of the Institute of Medicine guidelines. Unfortunately, efforts to improve appropriate gestational weight gain have had only limited success. To date, interventions have focused primarily on decreasing energy intake and/or increasing physical activity. Maternal resting energy expenditure, which comprises ˜60% of total energy expenditure compared with the ˜20% that comes from physical activity, may be an important consideration in understanding variations in gestational weight gain. OBJECTIVE: Our objective was to quantify the changes in resting energy expenditure during pregnancy and their relationship to gestational weight gain and body composition changes among healthy women. We hypothesized that greater gestational weight gain, and fat mass accrual in particular, are inversely related to variations in resting energy expenditure. STUDY DESIGN: We conducted a secondary analysis of a prospective cohort studied before conception and late pregnancy (34–36 weeks). Body composition (estimated using hydrodensitometry) and resting energy expenditure (estimated using indirect calorimetry) were measured. The relationship between the changes in resting energy expenditure and gestational weight gain and the change in fat mass and fat‐free mass were quantified. Resting energy expenditure was expressed as kilocalories per kilogram of fat‐free mass per day (kilocalories per kilogram of fat‐free mass–1/day–1) and kilocalories per day. Correlations are reported as r. RESULTS: Among 51 women, preconception body mass index was 23.0 (4.7) kg/m2; gestational weight gain was 12.8 (4.7) kg. Preconception and late pregnancy resting energy expenditure (kilocalories per day) correlated positively with the change in fat‐free mass (r = 0.37, P = .008; r = 0.51, P = .001). Late‐pregnancy resting energy expenditure (kilocalories per kilogram of fat‐free mass–1/day–1) was inversely associated with the change in fat mass (r = –0.34, P = .02) and gestational weight gain (r = –0.29, P = .04). From before pregnancy through late gestation, the increase in resting energy expenditure (kilocalories per day) correlated positively with the change in fat‐free mass (r = 0.44, P = .002) and negatively with the change in fat mass (r = –0.27, P = .06). CONCLUSION: The change in resting energy expenditure from before conception through late gestation correlated positively with changes in fat‐free mass but negatively with fat mass accrual. Women with smaller increases in resting energy expenditure across pregnancy had greater gestational weight gain, specifically more adipose tissue. These data suggest that resting energy expenditure is an important factor in gestational weight gain, particularly excess fat mass accrual. Future lifestyle intervention studies need to consider clinically feasible means of estimating resting energy expenditure and, in response, tailor nutrient intake and composition recommendations. Implementing and testing such interventions would be a novel approach to improve compliance with gestational weight gain guidelines.

Are the metabolic changes of pregnancy reversible in the first year postpartum

Early pregnancy prediction of third trimester glucose intolerance may identify a population of women whose trajectory toward gestational diabetes mellitus (GDM) is modifiable. We assessed whether first trimester glycated hemoglobin (HbA1c) and sex hormone-binding globulin (SHBG), markers of insulin resistance, predicted third trimester glucose intolerance. Nondiabetic women with singleton pregnancies enrolled in a prospective observational study, 11 0/7 to 14 6/7 weeks. At enrollment, maternal characteristics, medical history, and blood samples were collected for HbA1c and SHBG. Two-step GDM screening was performed, 22 0/7 to 33 6/7 weeks. A 50 g oral glucose tolerance test ≥ 130 mg/dL defined screen positive, or glucose intolerance. Carpenter-Coustan criteria diagnosed GDM. Means HbA1c and SHBG were compared between glucose-intolerant versus normoglycemic women, and GDM versus no GDM women. We report unadjusted and adjusted odds ratios (OR; 95% confidence interval [CI]) of regression analyses. Adjusted models include race, enrollment body mass index, and history of GDM. Among 250 women, 29% were glucose intolerant and 6% had GDM. Among glucose-intolerant women, HbA1c was higher (5.3 ± 0.3 vs. 5.1 ± 0.3, P = .01) and associated with glucose intolerance in unadjusted, but not adjusted, models (OR: 2.9, 95% CI: 1.2-7.1; adjusted odds ratio [aOR]: 2.0, 95% CI: 0.7-5.4). Among GDM women, HbA1c was higher (5.4 ± 0.4 vs 5.2 ± 0.3, P = .002) and SHBG was lower (228 ± 72 vs 288 ± 93 mmol/L, P = .02). The HbA1c predicted GDM in unadjusted (OR: 13.2,95% CI: 2.6-68.0) but not adjusted (aOR: 6.7, 95% CI: 0.8-55.2) models. Although metabolic alterations may well precede third trimester glucose intolerance, neither HbA1c of SHBG remained an independent predictor of glucose intolerance or GDM in adjusted models.Early pregnancy prediction of third trimester glucose intolerance may identify a population of women whose trajectory toward gestational diabetes mellitus (GDM) is modifiable. We assessed whether first trimester glycated hemoglobin (HbA1c) and sex hormone–binding globulin (SHBG), markers of insulin resistance, predicted third trimester glucose intolerance. Nondiabetic women with singleton pregnancies enrolled in a prospective observational study, 11 0/7 to 14 6/7 weeks. At enrollment, maternal characteristics, medical history, and blood samples were collected for HbA1c and SHBG. Two-step GDM screening was performed, 22 0/7 to 33 6/7 weeks. A 50 g oral glucose tolerance test ≥130 mg/dL defined screen positive, or glucose intolerance. Carpenter-Coustan criteria diagnosed GDM. Means HbA1c and SHBG were compared between glucose-intolerant versus normoglycemic women, and GDM versus no GDM women. We report unadjusted and adjusted odds ratios (OR; 95% confidence interval [CI]) of regression analyses. Adjusted models include race, enrollment body mass index, and history of GDM. Among 250 women, 29% were glucose intolerant and 6% had GDM. Among glucose-intolerant women, HbA1c was higher (5.3 ± 0.3 vs. 5.1 ± 0.3, P = .01) and associated with glucose intolerance in unadjusted, but not adjusted, models (OR: 2.9, 95% CI: 1.2-7.1; adjusted odds ratio [aOR]: 2.0, 95% CI: 0.7-5.4). Among GDM women, HbA1c was higher (5.4 ± 0.4 vs 5.2 ± 0.3, P = .002) and SHBG was lower (228 ± 72 vs 288 ± 93 mmol/L, P = .02). The HbA1c predicted GDM in unadjusted (OR: 13.2, 95% CI: 2.6-68.0) but not adjusted (aOR: 6.7, 95% CI: 0.8-55.2) models. Although metabolic alterations may well precede third trimester glucose intolerance, neither HbA1c of SHBG remained an independent predictor of glucose intolerance or GDM in adjusted models.