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PARC Pre-Congress session 2010 International Congress on Physical activity

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Dr. Michelle F. Mottola, Ph.D. FACSM Director,

R. Samuel McLaughlin Foundation –

Exercise and Pregnancy Laboratory

University of Western Ontario

London, Ont. N6A 3K7

mmottola@uwo.ca

Special thanks to:

Purpose of Workshop

1. To educate & inform women (& men) about the importance of physical activity during and after pregnancy

2. To increase understanding of PARmed-X for Pregnancy

3. To increase knowledge of current research in the area of physical activity and pre/post pregnancy

4. To discuss with others ways to promote and disseminate this information

5. To provide an opportunity to ask specific questions, and learn and share with other workshop participants about existing successful programs

• Historical guidelines for exercise during pregnancy

• PARmed-X for Pregnancy

• Research Evidence

• Exercise guidelines

• Safety considerations

• Community resources

Prenatal physical activity

Prior to 1985 Exercise Guidelines

for women did not exist.

REST!

In the Past

1985 ACOG (American College of Obstetrics & Gynecology) suggested heart rate should not go over 140 beats per minute

1994 ACOG Ignored heart rate; Replaced with common sense guidelines

2002 ACOG Ignored heart rate; Replaced with exercise on all days of week!

In the Past

CSEP & Health Canada (1996; Revised 2002; 2009)

PARmed-X for pregnancy

(Physical activity readiness, medical

prescreening & exercise prescription)

- written for physician/midwife or health care

professional to increase communication

Authors: L.A. Wolfe, Queens & M.F. Mottola, Western

Canadian guidelines for active living during pregnancy

**Joint SOGC/CSEP Clinical Practice Guideline 2003**

Davies et al. 2003; www.csep.ca

** Endorsed by the ACSM – Oct Bulletin 2004

** Endorsed by the CASM – March 2008 – Position Statement

** Used by PARC (OPHEA) – Goodlife Fitness (CANFitPro)

** Used by Middlesex-London Health Unit + Other Health Units

www.csep.ca

CSEP & Health Canada (1999)

Active Living During Pregnancy

Physical activity guidelines for mother & baby.

Author: Angela Kochan-Vintinner (Eds. Wolfe & Mottola)

Previously sedentary women with healthy pregnancies can safely start an exercise program in the second trimester

Women with low risk pregnancies can continue mild to moderate activity throughout

Mild to moderate aerobic activity within the Canadian guidelines (PARmed-X for Pregnancy) is considered safe

Muscle conditioning activity with necessary precautions is also considered safe (consult with a physical activity specialist )

Summary of Canadian Guidelines

(Physical activity readiness, medicalprescreening & exercise prescription)

• Written for physician/midwife or health care professional

Authors: L.A. Wolfe, Queens & M.F. Mottola, Western

PARmed-X for Pregnancy

• 4 page document

• current history of pregnant women & occupation

- list of contraindications to exercise

- absolute, relative

- Aerobic conditioning guidelines

F. (frequency) 3- 4 times /week

I. (intensity) target HR zones

T. (time) 15 up to 30 minutes

T. (type)

- Muscle conditioning guidelines & precautions

- Safety considerations & reasons to consult a physician/midwife/health care professional

Mottola et al. 2006 – Med. Sci. Sports Exerc. – new zonesVO2peak Prediction and Exercise Prescription for PregnantWomen. 38(8):1389-1395.

Target Heart Rate Zones:20-29 yearsFit – 145 – 160 beats/minuteUnfit – 129 - 144 beats/minute

30-39 yearsFit – 140 – 156 beats/minuteUnfit – 128 – 144 beats/minute

Age Heart Rate<20 140-15520-29 135-15030-39 130-145*heart rates if active

Heart Rates

Mottola et al. 2006 – Med. Sci. Sports Exerc. – new zonesVO2peak Prediction and Exercise Prescription for PregnantWomen. 38(8):1389-1395.

New Target Heart Rate Zones Based on Age & Fitness:

Age 20-29 years Target Heart Rate Based on FitnessLow 129-144Active 140-155Fit 145-160

Age 30-29 years Target Heart Rate Based on FitnessLow 128-144Active 130-145Fit 140-156

New Target Heart Rates

• Current guidelines present THR zones of 60-80% of max aerobic capacity -PARmed-X for Pregnancy

• These women may not be capable of exercise at this intensity• The ACSM (2005) suggest overweight and obese women initiate an

aerobic exercise program of 20 to 39% of VO2reserve

• Must be medically pre-screened• Target heart rate zones based on age:

• 20 to 29 years = 102 – 124 bpm; • 30 to 39 years = 101 – 120 bpm

For Overweight & Obese Pregnant

Women?

Davenport, Charlesworth, Vanderpank, Sopper & Mottola 2008. Appl Physiol Nut Metab 33: 984-89.

Pregnancy is time when many women change

to a healthier lifestyle

improve eating habits quit smoking stop alcohol use moderate caffeine consumption receptive to learning new info want to be good parents and do the best for their baby think about active living

Promotion of Physical Activity During Pregnancy

Most common advantages• Exercise improves mood

• Increases energy and stamina

Most common normative influences – (influence of people

that have an impact)• Family members and children

• Not physicians!

Most common advantages and influences

Physical limitations

Tiredness/fatigue

Time limits

Weight gain

Barriers to obstructing exercise

• help you and baby gain proper amount of weight

• reduce discomforts such as, backaches, leg cramps, constipation,

bloating, and swelling

• Improve mood, energy level and feelings about appearance

• Strengthen muscles and improve blood flow

• Improve sleep

• Help you have an easier, possibly shorter labour

• Help you recover from delivery & return to a healthy weight faster

Benefits of Regular Physical Activity

• Helps control blood sugar

• Improves heart and lung health

• Promotes health lifestyle for family

& children through role modeling

More benefits

• Benefits of being active during pregnancy

• Guidelines available for exercise during pregnancy (www.csep.ca)

• Identify barriers to being active and ways to overcome them

• Assistance in social support (health care providers, family

involvement, transportation, safety issues, facilities, subsidized

community programs)

Needs for Pregnant Women

1. Choose moderate activities unlikely to cause injury, such as, walking (most popular), aqua aerobics, swimming, yoga, or a stationary bike

2. Stop exercising if you feel tired, or are overheated

3. Drink plenty of water

4. Wear comfortable clothing that fits well and is supportive

5. Stop exercising if you feel dizzy, short of breath, pain in your back, swelling, numbness, sick to your stomach, or if your heart is beating too fast or at an uneven rate

6. Stop exercising if you have vaginal bleeding

7. Eat a well-balanced diet

8. Avoid center of gravity shifts

9. Avoid lying on your back for long periods of time

Safety Considerations

• Muscle conditioning activities – check out cupboard!!

• Increase steps taken per day –

park farther away; take stairs

• Rake leaves; cut grass

• Gardening

• Play with kids!

Other Ways to Promote Active Living

• Exercise education should be incorporated into pre

and post natal care.

• Importance of education and social support.

• Include babies & child care in programs

• Include PAR Q for Pregnancy in information packages

along with brochures on what activities are safe

Prenatal Education

Where to go for additional information?

Courses/classes

Reading materials

Community Resources

Some new research – the obesity link

Pregnancy link to obesity in mother and offspring

Risk factors for childhood obesity

Obesity prevention better than treatment??

Fetal Imprinting and maternal environment

Maternal Lifestyle during pregnancy

[Flegal et al. JAMA 2002; 288:1723-7].Prevalence of Obesity in the U.S:

30% of adults above 20 years age are now obese 60 million people!! 9 million children or teens are overweight!!

Health issues:• affects all organ systems• risk factor for hypertension• type 2 diabetes• cardiovascular mortality• dementia

Some new research – the obesity link

1. increased morbidity

2. adult obesity

3. related adverse metabolic and

cardiovascular problems

4. dyslipidemia tracks from childhood into adulthood

Childhood Obesity

Katzmarzyk PT. Canadian Medical Association Journal, 2002. Katzmarzyk PT. Obesity, 2008

200459% - OW23% - OB

Prevalence of Obesity in Canada

Adapted from Ritenbaugh C, Kumanyka S, Morabia A,

Jeffrey R, Antipatis V. OITF 1999

International National/regional Community Individualfactors factors factors factors

Marketglobalizat

ion

Industrialization

Media and marketing

Educational policies

Transportation policies

Urbanization policies

Health policies

Food policies

Family policies

Cultural policies

Publictransportation

Safety

City planning

Food availability and accessibility

Media and advertising

Income

Occupation

Leisure

Sports activities

Genetic

Energyexpenditure

Food intake

Food

BodyimageEconomic policies

Travel

Cover page of The Economist, December 13-19th, 2003.

• Women in reproductive years

• Pregnancy – excessive weight gain

• Post partum – excessive weight retention

• Menopause

• Adolescent females

Populations at risk for weight gain:

WOMEN

Obesity/overweight increases risk for Gestational Diabetes (GDM) about 17%

Maternal ObesityUp to 40%1 in 6 – obese1 in 3 - overweight

(Linne 2004)

National Geographic 2004

Among women of childbearing age, one

potential pathway for obesity development

is excessive pregnancy weight gain and

post partum weight retention

Pregnancy link to Obesity?

National Geographic 2004 Siega-Riz et al. 2004. Nut Rev 62:S105-11

• No exercise – Watching T.V. (sedentary lifestyle)

• Overweight/obesity;

• Body Mass Index – Weight/Height2 (BMI>25; >30kg/m2)

• GDM in previous pregnancy

• History of Large Babies > 9 lbs

• Family History of Diabetes

• Age

• Ethnicity – Aboriginal, Hispanic, South Asian, African

Risk factors for GDM…..

• Type 1• Later in life (type 2) • Large babies at risk for obesity which

is a risk factor for diabetes

Vicious Circle!!!

Offspring …..

• Higher birth weight predicted increased risk

of overweight in adolescence

• Born to a mother with GDM

• Lower birth weight associated with later risk for central

obesity

• Obese mother/ father

• Family life – overeating & sedentary lifestyle

Risk Factors for Childhood Obesity:

• Infants who were fed breast milk or who were breast fed

longer had lower risk of overweight in adolescence

• WHO breast fed at least 6 months Exclusively!!

• Parental feeding patterns

• Parental activity patterns

• Obese mother – obese child

Influence on early post-natal life

• Obesity prevention – begin very early in life?

• Obese preschoolers associated with

pre-pregnancy BMI of mother

• Children of obese mothers twice as likely

to be large for gestational age at birth

• Large for gestational age babies more likely

to be obese preschoolers

Whitaker 2004 Pediatrics

Obesity prevention better than obesity

treatment??

• Prevalence of obesity in children doubled over past 2-3 decades

• Appears to be accelerating

• Obesity & overweight are risk factors for type 2 diabetes

• Type 2 diabetes is no longer an adult disease – happens to younger

population including children

• Interventions (treatments) aimed at school age kids – TOO LATE!!

• PREVENTION!!!! EARLY YEARS??

Need Obesity prevention better than obesity treatment?? Title?

Prevention vs. treatment??

Intervention times?

• before conception

• during pregnancy

• early years of child’s life

Impact of maternal & child health on current

obesity epidemic

Causes:- input vs output- accelerated body weight gain- genetics; metabolic problems- excessive weight gain during

pregnancy & weight retention- fetal programming?

EATING HABITS

ACTIVITY

Awareness: Living in Balance

• diabetes during pregnancy • maternal glucose transferred to the fetus • large for gestational age infant• fat cell size and number determined in late pregnancy• risk of offspring for obesity and type 2 diabetes

• small for gestational age infants• inadequate maternal nutrition esp. protein• more at risk for central or truncal obesity• fat cell size and patterning early post natal life• problem with cardiovascular risk

Oken & Gillman, 2003 Obesity Res

Programming evidence:

- Assumption of patterning- Stimulus at critical

period of development has lasting effect

Trouble on both sides of the birth weight spectrum• in utero environment has profound effect on lifelong health• higher birth weight = higher BMI• lower birth weight = higher BMI

Oken & Gillman 2003; Catalano 2006

BMI

Birth Weight

Fetal Origins of Obesity:

BMI

Birth Weight

Mismatch

- under-nutrition fetal environment

- catch-up growth postpartum – rapid weight gain

- abdominal obesity

- large babies

- large adults

Birth weight/fat deposits

FetalProgramming??• Growing evidence that prenatal

environment impacts on chronic

disease risk in infant• increased fat mass accompanied

by glucose intolerance; insulin

resistance; diabetes; CV problems

National Geographic 2004

Birth Canal

HighInsulin

Baby Low Blood Sugars

High Sugars

Overworked pancreas

Fat Deposits

At Birth

Maternal ingestion of “junk

food” (heavily processed,

hyper-energetic) during

pregnancy and lactation

may increase junk food

preference of the offspring

and may increase the

propensity for offspring

obesity.........

Rat Study (Bayol et al. 2007):

In high-risk groups, GDM is

considered a significant initiating

factor in the type 2 diabetes/obesity

epidemic and thus prevention may

lead to decreased rates of type 2

diabetes in successive

generations!!

(Dyck et al. 2002)

GDM

If we restore the balance, can obesity and diabetes be prevented in future generations??

EatingHabits

Activity

Rat Study (Bayol et al. 2007):

fruit

cheese

steak

burrito

pasta potatobutter

1954 2004

1955

1900

1916

2004

1950’s

How can we make a difference in infancy?

How can we make a difference during

pregnancy??

SUPINEBLOOD FLOW MAY BE

RESTRICTED

STANDINGNO RESTRICTION OF

BLOOD FLOW

INFERIOR VENA CAVA

Position of Uterus against Inferior Vena

Cava

NORMAL DIASTASIS RECTI

Correct Posture in standing position

Keep the neck straight and the chin held upLift up through the chest cage

Keep the shoulders back; do not round shoulders forward

Be careful of (posterior pelvic tilt)Bend the knees slightly

Distribute the body weight on both feet

NEUTRAL PELVIC

ALIGNMENT

Daily activity before program:Pedometer Count: 5825.4 ±1794

Tudor-Locke & Bassett 2004

< 5000 Sedentary

5000 - 7499 Low Active

7500 - 9999 Somewhat Active

10,000 Active

>12,500 Highly Active

Steps/day Activity Index

• based on pedometer steps• 25 min/session; 3-4 X week• 2880±297 steps• add 2 min/wk until 40 min• 4854±559 steps• target HR ~ 118±6.8 bpm

5800 + 4800 = 10,300 steps per day (end of program)

Blood sugars monitored once per week – pre & post exercise with

glucometer

Davenport et al. 2008 Appl Physiol Nutr Metab 33:511-7.

Walking Program:

Capillary sugar – pre exercise (43 observations)One hour after eating = 7.8 ± 1.4 mmol/lCapillary sugar – post exercise5.3 ± 1.1 mmol/LWalking may help prevent insulin injections & help control capillary blood sugars

Walking effect on blood sugars?

EXERCISE

PREGNANCY

EVIDENCE-BASEDGUIDELINES!!!

RESEARCH QUESTIONS??

Rediscovering the “M” in “MCH”:

maternal health promotion after

childbirth

The science and practice of health

promotion after childbirth is less well

developed except for breast

feeding and family planning

Walker LO, Wilging S. JOGNN 2000;29:229-236

Activity - Postpartum

Reduce the risk of developing

heart disease, obesity and other

lifestyle-related diseases.

Improve women’s health and

well-being in the immediate

postpartum period.

Why should we promote health in the postpartum?

• Post-partum women who exercised during pregnancy can maintain their fitness levels at 2 months post delivery

• At 2 months post-partum, active women have lower resting blood pressure than active non-pregnant control women

• Major activity is walking up to 60 minutes with/without stroller by 2 months post-partum

• Most appear to have no problem with breastfeeding by 2 months post-partum

Summary of Preliminary Data

• Guidelines exist for exercise

during pregnancy, but relatively

little attention has been given to

exercise in the postpartum

period, and specific guidelines

for exercise in the postpartum

period are essentially nonexistent.

Guidelines

Regular physical activity essential to the health of women throughout

their life-span.

Benefits of exercise in the

postpartum period

Improved fitness

Less urinary stress incontinence

Less lactation-induced bone loss

Less postpartum weight retention

Improved psychosocial well-being

Barriers

Women are less likely than men to participate

in vigorous, regular exercise.

Exercise may be further compromised by

pregnancy and recovery from childbirth

Other barriers….

Downs & Hausenblas 2004. J.

MidwiferyWomens Health 49:138-44)

? others ?

Barriers to activity for new moms

Better understanding of

women’s health promotion in

the 1st postpartum year is an

essential step in addressing this

neglect in maternal health.

Barriers to activityfor new moms

Influence on early post-natal life

• Infants who were fed breast milk or who were breast

fed longer had lower risk of overweight in adolescence

• Parental feeding patterns

• Parental activity patterns

• Obese mother – Obese child

• Maternal influence as care-giver

• Rapid resumption of activities has no adverse effects,

but a gradual return to former activities is advised

• Medical Screening – PAR Q Med X for pregnancy:

www.csep.ca to download four page document

• Guidelines are the same for adult as for pregnant or

postpartum woman: from Canada’s Physical Activity

guide www.paguide.com

Guidelines form American College of Obstetricians and Gynecologists

for exercise during postpartum period, 2003

• Many physiological and morphological changes

remain from four to six weeks after delivery

• Is very individual – some women can begin back as

soon as two days after birth

• Hormones fluctuate leading to body imbalances

Exercise in postpartum period

• Important to continue breastfeeding

• Obese women tend to breastfed less often and shorter

duration

• Best to nurse before exercised to avoid discomfort

from engorged breasts.

• Avoids potential problems with increased acidity of

milk secondary to any build up of lactic acid

Activity & breastfeeding

Kegel exercises

Pelvic tilts

Shoulder rotations

Half crunches

Walking

What feels right for new mom

Important exercises

Using baby for post-natal activities

Using baby as resistance tool (carefully!!)

Have fun interacting with baby when doing push-ups(Active Living During Pregnancy, CSEP, 1999)

Examples of post-natal muscle

conditioning exercises

• Return to being active after pregnancy

has been associated with decreased

postpartum depression

• Only if exercise is stress relieving and

not stress provoking

BJ Sports Medicine 2003 :37

Returning to activity

We want to hear from you.

Do you have any programs, resources to share?

Add to our resource package.

Programs and Learnings “from the

field”

• Discuss ways to implement the learnings

from the workshop into programming that

you already do.

• Are there any ideas for new programs that you

could create?

• What are some ways to overcome some of the

barriers to being active?

Group Work

Thank you for your attention and participation –

we value your feedback!

Evaluation time

www.ophea.net/parc - soon

to be http://parc.ophea.net

Louise Daw

PARC Consultant

louise@ophea.org

519.646.2121

PARC’s contact information: