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Dr Karaponi Okesene-Gafa
Professor Lesley McCowan
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Outline
Title- Nutrition and PA, back to the basics
Maternal Obesity
• Global, NZ, Local scene
• Impact on pregnancy outcomes
• Can we break the cycle?
• Evidence – interventions during pregnancy
• The HUMBA trial
• Other NZ Research
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Global obesity epidemic the greatest human epidemic since 1990
NZ third most obese
in OECD
Best
Worst
Obese BMI >301 in 3 adults in NZ 1 in 4 in Australia
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Global obesity - children
NZ third most obese
in OECD
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Size of the problem in NZ :2013-14 Health Survey
30 % adults obese
Marked ↑ obesity in last 15 years
46% Maori adults obese
67% Pacific adults obese
One in three NZ children overweight / obese
44% Maori & 59% Pacific children overweight/ obese vs 28% European
No signs of epidemic abating
Costs of obesity in NZ exceed costs of cigarette smoking
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BMI in pregnancy Counties 2014
Obese (BMI > 30) who birthed at CMH facility
• 65% of Pacific mothers
• 45% of Maori
• 26% of European
Counties Maternity Quality and Safety report 2014/2015
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BMI of the women in CMH 2007 - 2009
Jackson report 2012
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Relative Risk
Miscarriage 2
Preeclampsia 2-3
Gestational diabetes 3-4
Caesarean section 2
Pulmonary embolism 2
Postpartum haemorrhage 1.4
Infection 2.2
Maternal Complications with Obesity in Pregnancy
Women with GDM have a 50% risk of T2DM
(obstetricexcellence.com.au)
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Gestational diabetes
http://chronicdiabetes.arccfn.org.au/47725/natural-ways-to-help-gestational-diabetes
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Diabetes in pregnancy 1991-2008, National Women’s Health
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
GD
M
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
Typ
e 1
an
d 2
GDM Type I Type 2
Increased GDM in parallel with obesity epidemic
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(Winnard 2012)
Diabetes in pregnancy CMH
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Relative Risk
Congenital abnormality 2-3
Stillbirth 2-3
Neonatal Death 1.4
Large for gestational age 2.4
Shoulder dystocia 2.0
Reduced breastfeeding 0.7
Later obesity child/adulthood 2-3
Baby Complications with maternal obesity
Humanpath.com
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Higher perinatal mortality in CMH
PMMRC 2015
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Increased risk of stillbirthAuckland Stillbirth Study
-1.5
-1
-0.5
0
0.5
1
1.5
0 10 20 30 40 50 60 70
Body Mass Index
Re
lati
ve
ad
just
ed
lo
g o
dd
s ra
tio
Dose dependent relationship
Stacey et al BMC pregnancy & childbirth 2011, 11:3
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Obesity and breast feeding
Delayed onset, initiation and duration of breastfeeding
Mechanisms- not understood Hormonal?
? Related to Caesarean section
? Difficulty latching with breast size
? Other factors related to SES, ethnicity
Urgent need for research to understand mechanisms
Jevitt J Midwifery Womens Health 2007;52:606
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What about pregnancy weight gain?
Institute of Medicine andNational Research Council, 2009 National Academy of Sciences
Pre-pregnancy BMI category
Total weight gain ( kg)
Underweight
(< 18.5 kg/m2)
12.5-18
Normal-weight
(18.5-24.9 kg/m2)
11.5-16
Overweight
(25.0-29.9 kg/m2)
7-11.5
Obese**
(≥ 30.0 kg/m2)
5-9
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Caesarean section
Large for gestational age infants
Preeclampsia
Gestational diabetes
Postpartum weight retention
Long term obesity mum & baby
Excess pregnancy weight gain
Complications ≈ to booking BMI
Women with normal BMI -↑ risk with ↑weight gain
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LGA
Preeclampsia
LSCS in labor Post-partum weight
Pregnancy complications & weight gain in pregnancy-
Rasmussen et al IOM guidelines 2009
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Excessive pregnancy weight gain a modifiable risk factor?
Tongan mother Fourth baby Body mass index 32 At 36 weeks of pregnancy
has gained 26 kg Caesarean birth required due to
big baby Most women gain excess
weight in pregnancy!
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Intergenerational cycle of obesity -diabetes
Excess fetalgrowth &
excess fat tissue
Newborn & childhood
obesity
Adult obesity +/-
type 2 diabetes
Abnormal metabolic environment in obese
pregnancy/GDM
http://chronicdiabetes.arccfn.org.au/47725/natural-ways-to-help-gestational-diabetes
Epigenetic effects
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Pregnancy a teachable moment
Pregnant women more likely to undergo behavioural change if their baby will benefit
Pregnancy a finite period of time where change more likely to be maintained
Effective interventions potential to influence lifelong health for mother and baby
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Interventions
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Effect of diet & exercise
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Dietary intervention & Outcome
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Evidence of Interventions
Dietary Intervention & Baby Outcomes
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Evidence – LIMIT trial
Adelaide (Australia)
1080 lifestyle intervention 1072 control
Large RCT pregnant women overweight/obese (25kg/m² and 30kg/m²)
Primary outcomes Secondary outcomes
Large for gestational age infants (LGA)
Infant
Maternal
Dietary intake & PA patterns
Psychological well being
Cost of healthcare
Dodd et al BMJ 10 Feb 2014;348:g1285 :g1285 doi: 10.1136/bmj.g1285
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Evidence – LIMIT trial
Results
42% women exceeded - recommended pregnancy weight gain
No LGA infants (>90th percentile)Or pregnancy weight gain with intervention
There was no overall reduction in clinical outcomes
No impact on emotional well being
Dodd et al BMJ 10 Feb 2014;348:g1285 :g1285 doi: 10.1136/bmj.g1285
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Evidence – LIMIT trial
Positive effects
Reduction Infant with weight >4kg - 0.56 (0.34 to 0.94)-18% babies >4kg
Women in lifestyle group increasedConsumption of fruits and vegesFibre content % of energy from saturated fats
physical activity360 MET units per week(15-20mins of brisk walking most days)
(Dodd et al. BMC Medicine 2014, 12:163)
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Evidence – UPBEAT trial
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UPBEAT – the UK pregnancies better eating and activity trial
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Women BMI >30 kg/m²8 hospitals Inner City UKMulti-ethnic populations> 16 years15-18 weeks gestation
Behavioural interventionN = 783
Standard antenatal care772
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ResultsThere were no differences in the main outcomes
Outcomes Groups N (%)
Gestational diabetesRR 0.96 (95% CI 0.79-1.16, p 0.68)
Standard care 172 (26)
Intervention 160 (25)
LGA babies (>90th %ile customised)Standard care 61 (8)
Intervention 71 (9)
However – women in the intervention group - Increased their PAReduced- dietary glycaemic load, gestational weight gain, and skin fold thickness
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Microbiome & ObesityNZ Herald Sat 7 September 2013
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Gut microbiome- many roles in health
Energy balance, provision of micronutients & fatty acids
Immune defenses
Composition differs in obese vs non-obese
Modification of microbiome may improve metabolic health
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Evidence - interventions
Probiotics modify the gut microbiome
“Live micro-organisms – when ingested in adequate amounts confer health benefit to the host” [FAO 2001]
Act – several ways
- antibacterial activity
- modulate systemic immune
- pathogen exclusion (bind to R sites) Probiotics
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RCT Probiotics (Finnish Trial)
Mothers 256
Diet education +Probiotics
Diet +Placebo
Control
Total 191 followed up in 24 months
General obstetric populationMarked ↓ GDM
GDM = 13% GDM = 36% GDM = 32%
(Luoto etal)
(Current = SPRING Trial in Australia RCT in 600 overweight/obese pregnant women)
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Text Messaging
Positive results with weight loss in non pregnant population
Beneficial effect with smoking cessation
Can be incorporated into clinical care
Incorporated in HUMBA dietary intervention
“Remember to only eat for you and not for two”
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Current research - HUMBA
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Background to HUMBA
External review of maternity care in CMH in 2012 noted the high perinatal mortality and the association with obesity
It recommended that:
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Our Research Journey
• Improved Health for me and my Baby
• Providing Childcare
• Allowing other family members to participate
• Programme in my own language
CompletedCompleted Completed Current
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Nutrition Survey Results
N = 422
Maternal Age Gestation Nulliparous ≥ 1 child
29 years 29 weeks 20% 80%
September – December 2013
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Results - BMI of Women
BMI during survey (%)
Total Maori
N=102
Pacific
N=171
Asian/OtherN=54
European
N=92
BMI <25 24% 12% 8% 61% 46%
Overweight BMI25-29.9 27% 25% 25% 30% 32%
Obesity >=30 47% 63% 66% 7% 16%
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Results - Knowledge
Knew about healthy eating? 99%
Received info – healthy eating? 95%
Most trusted source (Multiple answers)
Midwife 82%
GP 40%
Family/whanau 17%
Friends 5%
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Self reported healthy eating
Self reported Healthy Eating
Total
(%)
Maori
N=102
Pacific
N=171
Asian/OtherN=54
European
N=92
VeryFrequent 26% 4% 12% 63% 55%
Frequent 35% 37% 34% 33% 35%
Occasional 36% 55% 49% 4% 10%
Rare/Never 3% 4% 5% 0 0
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No Eating more Eating less
47% 44% 9%
Results – Eating habits
N=422
Changed?
N = 187 eating more
Cravings Eating for 2 Culture/Belief Family recom Nausea/V
70% 63% 32% 32% 17%
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Participation future program
Participate N (%)
Very Likely 221 (52)
Likely 131 (31)
Most important reasonImproved health of mum
and baby (81%)
Access %
Mobile 98
Internet 93
Ipad 88
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One to one n=292(69%)
c.f. Group n = 131(30%)
Preferred settings
Preferred location N (%)
Clinic 53 (41%)
Community Hall 40 (31%)
Most suitable day Never
Weekday Weekend
Thank you everyone who assisted with the survey
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Our Journey to HUMBA
completed completed
HUMBA pilot
Outcomes
Excess GWGFetal weight
completed
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HUMBA Main Objectives
To determine if dietary education and/or probiotics:
Reduce excessive pregnancy weight gain & improve glucose metabolism
Optimise infant birth weight
Reduce maternal and infant adiposity 4-6 months after birth
x
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Eligibility: 12-17 weeks of pregnancy BMI ≥ 30 Single baby No diabetes Not on probiotics Written informed consent
Randomised to: dietary education including text messages or routine dietary
advice and probiotics or placebo (N=220)
Who can take part in HUMBA?
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Routine dietary advice group
Receive the MoH information on:
Eating for Healthy Pregnant Women
AND
Healthy Weight gain in Pregnancy leaflet
Probiotics / placebo
No text messages
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4 education sessions:• Brief dietary and physical activity assessment
• Educating women (+/- family) regarding healthy diet and physical activity
• Helping women set 3 SMARTER goals at each visit
Text messages x3/week
Probiotics/Placebo
Intervention arm
Remember mum, whatever you eat I also eat –please choose carefully
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Women in the intervention group:
• Limit gestational weight gain 5-9kg
• Improve dietary intake (reducing fat, sugar increasing fibre, portion control)
• Improve levels of physical activity
Aims
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Diet intervention group - CHWs
CHWs Trained Certificate in Pacific Nutrition (AUT &National Heart Foundation)
Healthy conversations(Gravida)
Oversight – qualified dietitan
Handbook for mumswith recipes
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• Weight gain in pregnancy
• Aims of HUMBA
• How to limit gestational weight gain
• Additional nutrition issues
• Myths / cultural beliefs around food and exercise for weight
loss & in pregnancy
HUMBA handbook for mum
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1. Types of foods and drinks:Eat plenty “everyday” foodsLimit intake of “sometimes” foods - foods and drinks high in sugar and/or fat
2. Meal pattern:Aim for 3 meals per dayHealthy small snacks in-between meals
3. Portion control:Healthy plate model
Eating for 2 is not necessary!
4. Managing food cravings
5. Keeping physically active
Limiting pregnancy weight gain
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8 teaspoons sugar1 tsp
sugarNo Sugar, No Carbohydrate, No Calories
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Aim for 3 meals per day
• Common for people to skip meals, particularly breakfast (or first meal in the day)
• Aim for 4-5 hour gap between each meal– Doesn’t matter what time start eating in the day – sleep in/shift workers
• Aim to eat some carbohydrate food(s) at each meal
Meal pattern
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Healthy snacks
• Can include a small healthy snacks in-between meals.
• Swapping snacks
Meal pattern
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• Pre-HUMBA survey:
– Second most common reason for eating more I
“I’m eating for two”.
• Emphasize not eating for 2!
• Obese pregnant woman only need a small amount of extra food
– Equivalent: 2 small apples or 1 slice of bread per day
Portion control
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Healthy Plate Model
Portion control
Fist sizePalm size
Half the plate
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Pre-HUMBA survey: Cravings was the number one reason why pregnant women ate more.
Reassure women normal part of pregnancy
Cause: ?Hormonal changes
Doesn’t mean our body or baby is lacking in a certain nutrient
Cravings (head hunger)
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Physical hunger (from neck tostomach)
Head hunger (from neck up)
Stomach rumbling, lightheaded, grumpy, tired
Our brain telling us we are not (or are) happy about something. E.g bored, stressed, sad, happy, social, relaxing
Builds up over time Comes on quickly
Occurs around meal times Can be anytime of the day
Goes away after eating Doesn’t go away after eating
Eating leads to a feeling of satisfaction
Eating may lead to guilt and shame
Physical vs head hunger
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• If the craving hasn’t passed
– can you replace it with a healthier option?
Cravings cont…
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• Research tells us that dietary based programmes are the most effective in reducing gestational weight gain.
• Try to call it physical activity / movement rather than ‘exercise’.
• HUMBA aim: 30 minutes 3 times a week
– Can break it into smaller 10 minute sessions
Physical activity
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Visit 1: Increasing everyday physical activity
Visit 2: Keeping active throughout the day
Visit 4: Keeping active through leisure activities
Physical activity themes
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Others
• Reduce takeaways
• How to read food labels
• Meal planning
• Setting SMARTER goals
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Dietary Intervention in HUMBA
Summary
• 4 visits with Community Health Worker - goal setting!
• Portion size, not eating for two, healthy weight gain
• vegetables and fruit
• Managing cravings/mindfulness
• drink water and low fat milk not SSBs
• home cooked meals, healthy recipes & takeaways
• Label reading
• Increase physical activity- walking
• Motivational texts 3 X /week -reinforce education
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HUMBARCT
N = 220
LIPIDS entry 28 ,
36 wks and 5mths post
birth
HBA1c entry 28 ,
36 wks and 5mths post
birth
Urine & blood at entry & 36wks
Mother & offspring stool for
Microbiome
Maternal Follow up
studies
Childhood Follow up
studies
SCIENCE ALL PARTICIPANTS
SCIENCE CASE CONTROL
CHILDREN FOLLOW-UP
MATERNAL FOLLOW-UP
Research collaborations with HUMBA
Biobank
Breast feeding studies
Hair sample at 36 weeksmetabolome
Infancy & childhood
body composition
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• 47 recruited- recruitment slower than anticipated– Maori 14.8%
– Pacific Island 60.4%
– European 23.5%
– Indian 4.9%
– Asian 1.2%
– Other 2.5%
Will assess feasibility and success of our interventions in a high needs community
Community Health Worker as a dietary educator will be evaluated
Could be incorporated into models of care in pregnancy and elsewhere if successful
Progress to date
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How you can help?Keep a log of names & contact details & let us know by:
• Telephone: HUMBA 027 486 2200Cecile O’Driscoll 021 811 211Sarah Va'afusuaga 021 82 4071• Email: [email protected]• Fax HUMBA: 09 263 1385
• Like our facebook pagehttp://www.facebook.com/humba.nz
• Visit our websitehttp://www.humba.ac.nz/
• Give out hand outs
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AdvertisingPlease
Ask women you know/in your care– interested in participating
Give them a pamphlet
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Acknowledgements - funders
Cure Kids
Lottery Research Grant
Mercia Barnes Trust
University of Auckland
Counties Manukau Health
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Acknowledgements- funders & supporters
National Heart Foundation -
training of Community Health Workers
In kind support
Christian Hansen- probiotics
Roche International- equipment & consumables for HBA1c
New Zealand ColleMidwifery Council
CPD points recruitment to HUMBA
NIHI
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Acknowledgement - support
Research team
Midwives - LMCs, Community midwives, DHB, etc
GPs/Practice nurses
TAHA (Well Pacific Mother and Infant service)
Pacific Heart Beat (National Heart Foundation)
Pacific and Maori Health Team CMH
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The IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) Trial
Trial of stationary cycling from 20-36 weeks’ Overweight and obese women (n=75) Improved fitness but only 30% compliance with exercise
regime No improvement in :
Pregnancy weight gain Pregnancy outcomes Infant birthweight Maternal body composition
Not a solution at population level
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The NiPPeR Trial
Pre-pregnancy nutritional intervention Women planning to be pregnant (n=600 from Auckland) Receive a sachet with multiple micronutrients, probiotics
and myoinositol or placebo (standard pregnancy nutrients) -prior to pregnancy and continued until birth
Aim to determine whether pre-pregnany intervention that is continued during pregnancy improves maternal glucose metabolism and baby health
Recruitment due to start soon Limitation- those with most to benefit less likely to plan
pregnancy
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Conclusion
There is a worldwide epidemic of obesity
High prevalence of obesity in CMH populations
Interventions in pregnancy – shown to improve outcomes
We are trialling these in Counties (hoping to recruit a
Significant number of Pacific women)
Grateful to the funders and everyone assisting –recruitment
This study – requires a lot of collaboration
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Kia ora, Malo aupito, Faafetai, Meitaki maata
Fakaue lahi and Thank you