SeonAe Yeo

Language barriers and access to care.

The purpose of this chapter is to examine how language barriers contribute to health disparities among ethnic and racial minorities in the United States. A literature search was systematically conducted using selected computer databases (MEDLINE and CINAHL). Searches were limited to English-language-published research in the years from 1985 to 2003. A total of 47 published articles were included in this review. Overall these studies indicate that language barriers are associated with longer visit time per clinic visit, less frequent clinic visits, less understanding of physicians explanation, more lab tests, more emergency room visits, less follow-up, and less satisfaction with health services. The results also indicate that people who are older, poorer, and female tend to have severe language barriers compared to those who are younger, wealthier, and male. Improvement of communication between patients and providers in relation to health disparity consists of cultural competency and communication skills. Implications of these studies for practice and further research are outlined.The purpose of this chapter is to examine how language barriers contribute to health disparities among ethnic and racial minorities in the United States. A literature search was systematically conducted using selected computer databases (MEDLINE and CINAHL). Searches were limited to English-language-published research in the years from 1985 to 2003. A total of 47 published articles were included in this review. Overall these studies indicate that language barriers are associated with longer visit time per clinic visit, less frequent clinic visits, less understanding of physician’s explanation, more lab tests, more emergency room visits, less follow-up, and less satisfaction with health services. The results also indicate that people who are older, poorer, and female tend to have severe language barriers compared to those who are younger, wealthier, and male. Improvement of communication between patients and providers in relation to health disparity consists of cultural competency and communication skills. Implications of these studies for practice and further research are outlined.

Physical Activity and Pregnancy: Past and Present Evidence and Future Recommendations

Purpose. In this review, we provide researchers and practitioners with an overview of the physical activity and pregnancy literature to promote prenatal physical activity, improve measurement, further elucidate the role of activity in reducing maternal health complications, and inform future research. Method. We examined past and present physical activity and pregnancy studies and highlight key papers with a focus on maternal health outcomes to best inform physical activity promotion efforts. Results. We discuss: (a) historical overview of prenatal physical activity relative to the physical activity guidelines, how they have changed over time, and how evidence of the effect of prenatal activity on maternal/fetal health outcomes has affected clinical recommendations; (b) existing tools and challenges associated with measuring prenatal physical activity; (c) empirical evidence on multilevel determinants of prenatal activity to guide future intervention work; (d) empirical evidence of prenatal activity on adverse maternal outcomes (gestational diabetes mellitus, preeclampsia, excessive gestational weight gain) from observational and intervention studies; and (e) summary/recommendations for future research and practice. Conclusions. The physical activity and pregnancy literature has evolved over the past 50 years, and there is sufficient empirical evidence to support the promotion of moderate-to-vigorous prenatal physical activity for maternal health benefits. Future studies and interventions should be carefully designed, theoretically driven, and include validated and reliable activity measures. Researchers and practitioners should also consider the multifaceted determinants and outcomes of prenatal physical activity and intervene to promote physical activity before, during, and after pregnancy.

Guidelines for Physical Activity During Pregnancy Comparisons From Around the World

Introduction. Women attain numerous benefits from physical activity during pregnancy. However, because of physical changes that occur during pregnancy, special precautions are also needed. This review summarizes current guidelines for physical activity among pregnant women worldwide. Methods. We searched PubMed (MedLINE) for country-specific governmental and clinical guidelines on physical activity during pregnancy through the year 2012. We cross-referenced with articles referring to guidelines, with only the most recent included. An abstraction form was used to extract key details and summarize. Results. In total, 11 guidelines were identified from 9 countries (Australia, Canada, Denmark, France, Japan, Norway, Spain, United Kingdom, United States). Most guidelines supported moderate-intensity physical activity during pregnancy (10/11) and indicated specific frequency (9/11) and duration/time (9/11) recommendations. Most guidelines provided advice on initiating an exercise program during pregnancy (10/11). Six guidelines included absolute and relative contraindications to exercise. All guidelines generally ruled-out sports with risks of falls, trauma, or collisions. Six guidelines included indications for stopping exercise during pregnancy. Conclusion. This review contrasted pregnancy-related physical activity guidelines from around the world, and can help inform new guidelines as they are created or updated and facilitate the development of a worldwide guideline.

A Comparison of Walking versus Stretching Exercises to Reduce the Incidence of Preeclampsia: A Randomized Clinical Trial

Objectives. To compare a walking exercise to a stretching exercise during pregnancy in high-risk women who were sedentary and had previously experienced preeclampsia. Methods. A randomized clinical trial of the effects of the two types of physical exercises was conducted between November 2001 and July 2006 in Washtenaw County, Michigan. Both groups engaged in the assigned exercise five times a week until the end of pregnancy. Results. Women were randomized to either the walking group (n = 41) or the stretching group (n = 38). The walkers exercised an average of 36 (SD, 6) minutes at 18 weeks gestation, 34 (SD, 7) minutes at 28 weeks gestation, and 31 (SD, 12) minutes at the last week of the intervention. On average, they exercised within target heart rate ranges 35% (SD, 32%) at 18 weeks gestation, 22% (SD, 25%) at 28 weeks gestation, and 17% (SD, 25%) at the last week of the intervention. The stretching group engaged in stretching exercises following a 40-minutes videotape. On average, the walking group exercised 4 (SD, 1) times a week at 18 weeks gestation, 4 (SD, 1) time a week at 28 weeks gestation, and 3 (SD, 1) times a week at the last week of the intervention. Equally on average, the stretching group exercised 4 (SD, 2) times a week at 18 weeks gestation, 5 (SD, 1) times a week at 28 weeks gestation, and 3 (SD, 1) times a week at the last week of the intervention. No difference between groups was observed, but both exercised significantly less frequently over the time (p < 0.0001). Together, participants reported average 7,040 (SD, 2,612) steps at the beginning and 5,711 (SD, 2,739) steps at the end of the study. The walkers tracked an average 8,501 (SE, 778) steps a day at 20 weeks gestation and 7,418 (SE, 788) steps at 34 weeks gestation (n.s.). The stretchers tracked an average 6,189 (SE, 704) steps at 20 weeks gestation and 4,848 (SE, 452) steps at 34 weeks gestation (p < 0.05). The incidence of preeclampsia was 14.6% (95% CI, 5.6 to 29.2) among the walkers and 2.6% (95% CI; 0.07 to 13.8) among the stretchers. The incidence of gestational hypertension was 22 % (95% C.I., 8.7 to 35.2) for the walkers and 40% (95% CI, 23.2 to 55.8) for the stretchers. The mean transferrin level, an antioxidant marker, was significantly higher in the stretching group mean (412 mg/dL, 95%CI, 389 to 435) than the walkers at the time of labor (mean = 368 mg/dL, 95%CI, 346 to 391) (p < 0.05). No significant group differences were observed in birth outcomes. Conclusion. Regular stretching exercises may promote endogenous antioxidants among women at risk for preeclampsia.

Adherence to walking or stretching, and risk of preeclampsia in sedentary pregnant women†

Pregnant women at risk for preeclampsia may benefit from the positive effects of exercise, but they may be unlikely to adhere to an exercise program. A randomized trial was conducted with 124 sedentary pregnant women to compare the effects of walking exercise to a stretching exercise on adherence and on the preeclampsia risk factors of heart rate (HR), blood pressure, and weight gain. Walkers exercised less than stretchers both overall and as pregnancy advanced. HR and blood pressure were lower among stretchers than walkers, but weight gain did not differ between the groups. For sedentary pregnant women, a stretching exercise may be more effective than walking in mitigating the risk of preeclampsia due to higher adherence and possible cardiac-physiologic effects.

Effects of antenatal diet and physical activity on maternal and fetal outcomes: Individual patient data meta-analysis and health economic evaluation

BACKGROUND Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes. OBJECTIVES To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search). REVIEW METHODS Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions. RESULTS Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI -0.92 to -0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate -0.10 kg, 95% CI -0.14 to -0.06 kg) and multiparity (summary estimate -0.73 kg, 95% CI -1.24 to -0.23 kg). LIMITATIONS The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies. CONCLUSION Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes. FUTURE WORK The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003804. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Dietary interventions in overweight and obese pregnant women: a systematic review of the content, delivery, and outcomes of randomized controlled trials.

CONTEXT Interventions targeting maternal obesity are a healthcare and public health priority. OBJECTIVE The objective of this review was to evaluate the adequacy and effectiveness of the methodological designs implemented in dietary intervention trials for obesity in pregnancy. DATA SOURCES A systematic review of the literature, consistent with PRISMA guidelines, was performed as part of the International Weight Management in Pregnancy collaboration. STUDY SELECTION Thirteen randomized controlled trials, which aimed to modify diet and physical activity in overweight and obese pregnant women, were identified. DATA SYNTHESIS There was significant variability in the content, delivery, and dietary assessment methods of the dietary interventions examined. A number of studies demonstrated improved dietary behavior in response to diet and/or lifestyle interventions. Nine studies reduced gestational weight gain. CONCLUSION This review reveals large methodological variability in dietary interventions to control gestational weight gain and improve clinical outcomes in overweight and obese pregnant women. This lack of consensus limits the ability to develop clinical guidelines and apply the evidence in clinical practice.

Possible Beneficial Effect of Exercise, by Reducing Oxidative Stress, on the Incidence of Preeclampsia

We hypothesize that regular exercise enhances antioxidative enzymes in pregnant women, which reduce oxidative stress and, thus, the incidence of preeclampsia. Oxidative stress with enhanced lipid peroxide formation could lead to endothelial dysfunction in preeclampsia. Other conditions, such as increased transferrin saturation and decreased iron-binding capacity, directly and indirectly promote the process of oxidative stress and subsequent endothelial dysfunction. Exercise increases oxidative metabolism and produces a prooxidant environment. This acidic environment during exercise (at or beyond anaerobic threshold) promotes oxygen release from hemoglobin and increases in PO(2) in tissues, as well as releases iron from transferrin. When exercise is repeated regularly, the body promptly adjusts so that oxidative stress is eliminated or reduced. The bodys adaptations to a regular exercise habit seem to have an antioxidant effect. In humans, training effects have been identified with an enhanced activity of antioxidative enzymes. Another concerted adaptation that regular exercise brings to womens bodies is resistance against production of prooxidants by increasing the number of mitochondria. Equally important is a training effect that decreases susceptibility to lipid peroxidation. Evidence suggests that physically active women are less likely to develop preeclampsia. In theory, intracellular and extracellular conditions resulting from regular exercise should counteract the enhancement of oxidative stress, thus interfering with the process leading to endothelial dysfunction. This position paper describes a hypothesis and includes a brief review of exercise physiology and biochemical research in preeclampsia. Unlike other preventive treatments, such as aspirin or calcium supplements, a regular exercise habit leads to a positive and healthy lifestyle without concern of side effects.

Study protocol: differential effects of diet and physical activity based interventions in pregnancy on maternal and fetal outcomes-individual patient data (IPD) meta-analysis and health economic evaluation

BackgroundPregnant women who gain excess weight are at risk of complications during pregnancy and in the long term. Interventions based on diet and physical activity minimise gestational weight gain with varied effect on clinical outcomes. The effect of interventions on varied groups of women based on body mass index, age, ethnicity, socioeconomic status, parity, and underlying medical conditions is not clear. Our individual patient data (IPD) meta-analysis of randomised trials will assess the differential effect of diet- and physical activity-based interventions on maternal weight gain and pregnancy outcomes in clinically relevant subgroups of women.Methods/designRandomised trials on diet and physical activity in pregnancy will be identified by searching the following databases: MEDLINE, EMBASE, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database. Primary researchers of the identified trials are invited to join the International Weight Management in Pregnancy Collaborative Network and share their individual patient data. We will reanalyse each study separately and confirm the findings with the original authors. Then, for each intervention type and outcome, we will perform as appropriate either a one-step or a two-step IPD meta-analysis to obtain summary estimates of effects and 95% confidence intervals, for all women combined and for each subgroup of interest. The primary outcomes are gestational weight gain and composite adverse maternal and fetal outcomes. The difference in effects between subgroups will be estimated and between-study heterogeneity suitably quantified and explored. The potential for publication bias and availability bias in the IPD obtained will be investigated. We will conduct a model-based economic evaluation to assess the cost effectiveness of the interventions to manage weight gain in pregnancy and undertake a value of information analysis to inform future research.Systematic review registrationPROSPERO 2013:CRD42013003804

What characteristics of nutrition and physical activity interventions are key to effectively reducing weight gain in obese or overweight pregnant women? A systematic review and meta-analysis

Lifestyle interventions targeting gestational weight gain (GWG) report varying degrees of success. To better understand factors influencing efficacy, we reviewed randomized trials specifically among obese and overweight pregnant women.