生活型態諮商有助於改善某些懷孕結果


  【24drs.com】根據線上發表於PLoS Medicine的群組隨機試驗結果,高風險孕婦進行生活型態諮商可控制新生兒的出生體重,但是對於母親的妊娠糖尿病(gestational diabetes mellitus,GDM)沒有影響。
  
  芬蘭Tampere UKK健康促進研究中心的Riitta Luoto等人寫道,多攝取飽和脂肪、少攝取多元不飽和脂肪、妊娠時體重增加過多可能會增加GDM的風險,體能活力則與降低GDM風險有關;生活型態調整顯示可作為GDM的輔助治療,但是,對於GDM的主要預防,迄今還沒有適當的有力試驗。
  
  NELLI研究的目的是評估生活型態諮商對於高風險GDM孕婦的影響、以及減少高出生體重新生兒的結果;芬蘭的14個城市中,有2,271名婦女在懷孕8-12週時進行口服葡萄糖耐受測試(OGTT),結果發現其中399名血糖正常婦女有1個以上的GDM風險因素,例如身體質量指數(BMI)為25 kg/m2以上、葡萄糖不耐症或前一胎的新生兒體重過重(≧4500 g)、糖尿病家族史、40歲以上。
  
  介入組的婦女在5次產檢中接受有關體能活力、飲食與體重控管的個人強化諮商,孕婦方面的研究終點是以OGTT確認GDM的發生率,新生兒方面的主要研究終點是以妊娠年紀校正新生兒出生體重;另外也評估母親在懷孕期間的體重增加和胰島素需求情況。校正群組、產科診所以及護士程度的影響、以及孕婦年紀、教育程度、一致性、懷孕前的BMI等變項以進行多水平分析。
  
  體能活力和飲食組成的改變反映出對介入的良好順從度;GDM定義為,妊娠26-28週時,2小時OGTT至少1個異常值,發生GDM的介入組有15.8% (34/216)名婦女 、一般照護組有12.4% (22/179) (絕對影響程度為1.36;95%信心區間[CI]為 0.71 - 2.62;P = .36)。
  
  相較於一般照護組,介入組整體有較低的新生兒出生體重(絕對影響程度為-133 g;95% CI,-231至-35;P = .008)、新生兒大小超過妊娠期(LGA)的比率較少(26/216,12.1% vs 34/179,19.7%;P = .042)。
  
  比較介入組和一般照護組的婦女,GDM的風險(定義為妊娠26-28週時,2小時OGTT至少1個異常值;新生兒體重至少4000 g或孕婦使用胰島素或其他糖尿病藥物)分別是27.3% vs 33.0% (P = .43),LGA新生兒風險分別是7.3% vs 19.5% (P = .03)。
  
  研究作者寫道,介入後可有效控制新生兒出生體重,但是無法影響母親的GDM。
  
  研究限制包括,沒有測量懷孕後期的母親葡萄糖耐受度、沒有做到雙盲。
  
  研究作者結論指出,進行中的臨床試驗結果可強化「生活型態調整會影響母親和胎兒高血糖及後遺症的結果」的證據,我們的研究發現強調,孕婦照護應注意有關體能活力、飲食、體重的諮商,特別是有GDM風險的孕婦,以預防可能造成分娩問題的新生兒LGA,也有助於孕婦及孩童未來的體重控制。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=6523&x_classno=0
  

Lifestyle Counseling May Improve Some Pregnancy Outcomes

By Laurie Barclay, MD
Medscape Medical News

May 17, 2011 — Lifestyle counseling of high-risk pregnant women controls newborn birth weight but fails to affect maternal gestational diabetes mellitus (GDM), according to the results of a cluster-randomized trial reported online May 17 in PLoS Medicine.

"High intake of saturated fat, low intake of polyunsaturated fat, and excessive gestational weight gain may increase the risk of GDM," write Riitta Luoto, from UKK Institute for Health Promotion Research in Tampere, Finland, and colleagues. "Physical activity is also associated with decreased risk of GDM. Lifestyle modifications have been shown to be a valuable adjunctive therapy of GDM but to date there are no adequately powered trials on primary prevention of GDM."

The goal of the NELLI study was to assess the effect of lifestyle counseling in pregnant women at high risk for GDM on development of maternal GDM and on reducing high birth weight in the newborns. In 14 municipalities in Finland, 2271 women were screened with an oral glucose tolerance test (OGTT) at 8 to 12 weeks of gestation. This identified 399 euglycemic women with 1 or more risk factors for GDM, namely body mass index (BMI) of 25 kg/m2 or more, glucose intolerance or newborn macrosomia (? 4500 g) in a previous pregnancy, family history of diabetes, and age 40 years or older.

Women in the intervention group received individual intensified counseling regarding physical activity, diet, and weight gain at 5 antenatal visits. The main maternal study endpoint was incidence of GDM identified by OGTT, and the main neonatal study endpoint was newborn birth weight adjusted for gestational age. Maternal weight gain and insulin requirement during pregnancy were also assessed. Cluster, maternity clinic, and nurse level effects, as well as age, education, parity, and prepregnancy BMI, were adjusted for in multilevel analyses.

Changes in physical activity and in dietary composition reflected good adherence to the intervention. GDM, defined as at least 1 abnormal value in 2-hour OGTT at 26 to 28 weeks of gestation, developed in 15.8% (34/216) of women in the intervention group vs 12.4% (22/179) of those in the usual-care group (absolute effect size, 1.36; 95% confidence interval [CI], 0.71 - 2.62; P = .36).

Compared with the usual-care group, the intervention group overall had lower neonatal birth weights (absolute effect size, ?133 g; 95% CI, ?231 to ?35; P = .008) and a lower proportion of large-for-gestational-age (LGA) newborns (26/216, 12.1% vs 34/179, 19.7%; P = .042).

For adherent women in the intervention group vs those in the usual-care group, the risk for GDM, defined as at least 1 abnormal value in 2-hour OGTT at 26 to 28 weeks of gestation, newborn birth weight of at least 4000 g, or use of insulin or other diabetic medication, was 27.3% vs 33.0% (P = .43), and the risk for LGA newborns was 7.3% vs 19.5% (P = .03).

"The intervention was effective in controlling birthweight of the newborns, but failed to have an effect on maternal GDM," the study authors write.

Limitations of this study include lack of late pregnancy measurement of maternal glucose intolerance and lack of blinding.

"Results from ongoing clinical trials may strengthen the evidence on the effectiveness of lifestyle modifications on maternal and fetal hyperglycemia and its consequences," the study authors conclude. "The findings of our study emphasize counseling on the topics of physical activity, diet, and weight gain in maternity care especially for women at risk for GDM in order to prevent LGA newborns possibly causing problems in delivery, and both the mother's and the child's later weight development."

(Finnish) Diabetes research fund, and Competitive research funding from Pirkanmaa hospital district, Academy of Finland, Ministry of Education, and Ministry of Social Affairs and Health supported this study. The study authors have disclosed no relevant financial relationships.

PLoS Med. Published online May 17, 2011.

    
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