Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials

Objective To synthesise the evidence on the overall and differential effects of interventions based on diet and physical activity during pregnancy, primarily on gestational weight gain and maternal and offspring composite outcomes, according to women’s body mass index, age, parity, ethnicity, and pre-existing medical condition; and secondarily on individual complications.

Design Systematic review and meta-analysis of individual participant data (IPD).

Data sources Major electronic databases from inception to February 2017 without language restrictions.

Eligibility criteria for selecting studies Randomised trials on diet and physical activity based interventions in pregnancy.

Data synthesis Statistical models accounted for clustering of participants within trials and heterogeneity across trials leading to summary mean differences or odds ratios with 95% confidence intervals for the effects overall, and in subgroups (interactions).

Results IPD were obtained from 36 randomised trials (12 526 women). Less weight gain occurred in the intervention group than control group (mean difference −0.70 kg, 95% confidence interval −0.92 to −0.48 kg, I2=14.1%; 33 studies, 9320 women). Although summary effect estimates favoured the intervention, the reductions in maternal (odds ratio 0.90, 95% confidence interval 0.79 to 1.03, I2=26.7%; 24 studies, 8852 women) and offspring (0.94, 0.83 to 1.08, I2=0%; 18 studies, 7981 women) composite outcomes were not statistically significant. No evidence was found of differential intervention effects across subgroups, for either gestational weight gain or composite outcomes. There was strong evidence that interventions reduced the odds of caesarean section (0.91, 0.83 to 0.99, I2=0%; 32 studies, 11 410 women), but not for other individual complications in IPD meta-analysis. When IPD were supplemented with study level data from studies that did not provide IPD, the overall effect was similar, with stronger evidence of benefit for gestational diabetes (0.76, 0.65 to 0.89, I2=36.8%; 59 studies, 16 885 women).

Conclusion Diet and physical activity based interventions during pregnancy reduce gestational weight gain and lower the odds of caesarean section. There is no evidence that effects differ across subgroups of women.

Reference: BMJ 2017;358:j3119

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The financial challenges facing general practice

Future-Focused Finance and the HFMA have worked together to produce this briefing on the current financial challenges facing general practice.

We asked general practitioners (GPs) and practice managers about the current financial challenges they are facing Their responses highlight a number of serious concerns about the issues facing general practice and in this briefing we make a number of recommendations to address some of the most pressing issues.

General practice is facing unprecedented pressures and, with GPs managing heavier and more complex workloads, uncertainty about a sustainable future in a rapidly changing landscape is understandable. In such a stretched environment general practice needs guidance and support to manage the status quo, let alone deliver the increasing expectations set out in Next steps on the NHS five year forward view.

Further information is available here.

Roll out of NHS Wi-Fi to GP surgeries begins

NHS Digital has begun roll out of NHS WiFi to GP surgeries in England and it should be completed by the end of the year.

Using NHS WiFi, patients will be able to access the internet free of charge in their GP’s waiting room, via their smart phone or tablet. It will enable patients to link in with local health clinics and services and is paving the way for future developments in digital patient care.

NHS WiFi will provide a secure, stable, and reliable WiFi capability, consistent across all NHS settings. It will allow patients and the public to download health apps, browse the internet and access health and care information.

Local Clinical Commissioning Groups (CCGs) are responsible for choosing a supplier that can provide an NHS WiFi compliant system which suits their needs, and working with them to implement it across their local NHS sites. The chosen system must be based on a set of policies and guidance defined by NHS Digital.

Guidance available via NHS Digital relates to implementing NHS WiFi in GP practices. Hospitals and secondary care will follow in 2018.

Further details available here

RCGP launches strategic plan

Great doctors, great care sets out the College’s four main objectives for the next three years. It also defines 12 ‘values’, applicable to College members and employees, that will shape how they go about achieving these goals.

Four objectives

The College has identified four objectives that explain its purpose and what it is aiming to achieve over the next three years:

  1. Shape the future of General Practice
  2. Ensure GP education meets the changing needs of UK primary care
  3. Grow and support a strong, engaged membership
  4. Be the voice of the GP (influence)

Vision and values

The College has also identified 12 values, which can be summarised in four ‘core’ values:

  • Excellence
  • Teamwork
  • Leadership
  • Care

Commenting on the plan, RCGP Chair, Professor Helen Stokes-Lampard, said: “I am immensely proud to be Chair of this College, representing and supporting over 52,000 hardworking and dedicated family doctors in delivering quality care to patients.

“General practice is the foundation of the NHS. Our service is revered worldwide. We aim to keep it that way and to continue to improve and innovate.

“I’m confident that with our new strategic plan enabling us to focus our work, the College will be able to provide greater support for general practice and patient care across the UK and internationally.”

Reference: Great doctors, great care: RCGP strategic plan 2017-2020

Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study

Objectives To determine how soon after delivery the risk of post-pregnancy hypertension increases in women with hypertensive disorders of pregnancy and how the risk evolves over time.

Design Nationwide register based cohort study.

Setting Denmark.

Populations 482 972 primiparous women with a first live birth or stillbirth between 1995 and 2012 (cumulative incidence analyses), and 1 025 118 women with at least one live birth or stillbirth between 1978 and 2012 (Cox regression analyses).

Main outcome measures 10 year cumulative incidences of post-pregnancy hypertension requiring treatment with prescription drugs, and hazard ratios estimated using Cox regression.

Results Of women with a hypertensive disorder of pregnancy in a first pregnancy in their 20s, 14% developed hypertension in the first decade post partum, compared with 4% of women with normotensive first pregnancies in their 20s. The corresponding percentages for women with a first pregnancy in their 40s were 32% and 11%, respectively. In the year after delivery, women with a hypertensive disorder of pregnancy had 12-fold to 25-fold higher rates of hypertension than did women with a normotensive pregnancy. Rates in women with a hypertensive disorder of pregnancy were threefold to 10-fold higher 1-10 years post partum and remained twice as high even 20 or more years later.

Conclusions The risk of hypertension associated with hypertensive disorders of pregnancy is high immediately after an affected pregnancy and persists for more than 20 years. Up to one third of women with a hypertensive disorder of pregnancy may develop hypertension within a decade of an affected pregnancy, indicating that cardiovascular disease prevention in these women should include blood pressure monitoring initiated soon after pregnancy.

Reference: BMJ 2017;358:j3078

Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses’ Health Study II: observational cohort study

Objectives To study the association between lifestyle risk factors and chronic hypertension by history of hypertensive disorders of pregnancy (HDP: gestational hypertension and pre-eclampsia) and investigate the extent to which these risk factors modify the association between HDP and chronic hypertension.

Design Prospective cohort study.

Setting Nurses’ Health Study II (1991-2013).

Participants 54 588 parous women aged 32 to 59 years with data on reproductive history and without previous chronic hypertension, stroke, or myocardial infarction.

Main outcome measure Chronic hypertension diagnosed by a physician and indicated through nurse participant self report. Multivariable Cox proportional hazards models were used to investigate the development of chronic hypertension contingent on history of HDP and four lifestyle risk factors: post-pregnancy body mass index, physical activity, adherence to the Dietary Approaches to Stop Hypertension (DASH) diet, and dietary sodium/potassium intake. Potential effect modification (interaction) between each lifestyle factor and previous HDP was evaluated with the relative excess risk due to interaction.

Results 10% (n=5520) of women had a history of HDP at baseline. 13 971 cases of chronic hypertension occurred during 689 988 person years of follow-up. Being overweight or obese was the only lifestyle factor consistently associated with higher risk of chronic hypertension. Higher body mass index, in particular, also increased the risk of chronic hypertension associated with history of HDP (relative excess risk due to interaction P<0.01 for all age strata). For example, in women aged 40-49 years with previous HDP and obesity class I (body mass index 30.0-34.9), 25% (95% confidence interval 12% to 37%) of the risk of chronic hypertension was attributable to a potential effect of obesity that was specific to women with previous HDP. There was no clear evidence of effect modification by physical activity, DASH diet, or sodium/potassium intake on the association between HDP and chronic hypertension.

Conclusion This study suggests that the risk of chronic hypertension after HDP might be markedly reduced by adherence to a beneficial lifestyle. Compared with women without a history of HDP, keeping a healthy weight seems to be especially important with such a history.

Reference:  BMJ 2017;358:j3024

Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain. The Mint Randomized Clinical Trials

Question  What is the effectiveness of radiofrequency denervation added to a standardized exercise program for patients with chronic low back pain?

Findings  In 3 randomized clinical trials including 681 participants with chronic low back pain originating from the facet joints, sacroiliac joints, or a combination of these or the intervertebral disks, radiofrequency denervation combined with exercise compared with exercise alone resulted in either no significant difference in pain intensity, or a difference smaller than the prespecified minimal clinically important difference after 3 months.

Meaning  The study findings do not support the use of radiofrequency denervation for chronic low back pain originating from these sources.

Reference: JAMA. 2017;318(1):68-81.