1. ACTIVE LIVING DURING PREGNANCY & POST PARTUM Dr. Michelle F. Mottola, Ph.D. FACSM Director, R. Samuel McLaughlin Foundation- Exercise and Pregnancy Laboratory University of Western Ontario London, Ont. Canada N6A 3K7 Email: mmottola@uwo.ca

2. Wolfe et al. Sports Med 1989;8:273-301 MATERNAL AND FETAL WELL-BEING Optimal zone for maternal exercise prescription chronic fatigue fetal death musculo- skeletal injury prematurity fetal growth restriction altered fetal development BASELINE Threshold for maternal physical conditioning effects QUANTITY AND QUALITY OF MATERNAL EXERCISE decrease increase  metabolic and cardiopulmonary reserve promotion of normal glucose tolerance psychological benefits Maternal dose-response curve Fetal dose-response curve fetal and placental adaptations

3. IMPORTANCE OF MEDICAL PRESCREENING THRESHOLD FOR PROBLEMS??

4. Prior to 1985 Exercise Guidelines for Pregnant Women did not exist – REST!! 1985 – ACOG suggested heart rate should not go above 140 beats per minute 1994 – ACOG Ignored heart rate; Replaced with common sense guidelines HISTORICALLY: 2002 – ACOG Ignored heart rate; Replaced with exercise on all days of week!!

5. Canadian guidelines for active living during pregnancy **Joint SOGC/CSEP Clinical Practice Guideline 2003** CSEP & Health Canada (1996 Revised 2002) PARmed-X for Pregnancy (Physical activity readiness, medical prescreening & exercise prescription) - written for physician/midwife or health care professional Authors: L.A. Wolfe, Queens & M.F. Mottola, Western CSEP & Health Canada (1999) Active Living During Pregnancy Physical activity guidelines for mother & baby. Author: Angela Kochan-Vintinner (Eds. Wolfe & Mottola) www.csep.ca

7. - 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 physician/midwife PARmed-X for Pregnancy

8. Occupational activity did not impact on birth weight Structured exercise frequency during late pregnancy appears to be a determinant of birth weight Too much vs too little vs just right!! ***** 3 – 4 times per week ****** Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

9. Mottola et al. 2006 – Med. Sci. Sports Exerc. – new zones VO2peak Prediction and Exercise Prescription for Pregnant Women. 38(8):1389-1395. Target Heart Rate Zones: 20-29 years Fit – 145 – 160 beats/minute Unfit – 129 - 144 beats/minute 30-39 years Fit – 140 – 156 beats/minute Unfit – 128 – 144 beats/minute

10. Summary of Canadian Guidelines 1. Previously sedentary women with healthy pregnancies can safely start an exercise program in the second trimester 2. Women with low risk pregnancies can continue mild to moderate activity throughout 3.Mild to moderate aerobic activity within the Canadian guidelines (PARmed-X for Pregnancy) is considered safe 4. Muscle conditioning activity with necessary precautions is also considered safe

11. Adapted from Wolfe et al., 1989 MATERNAL AND FETAL WELL-BEING Optimal zone for maternal exercise prescription BASELINE QUANTITY AND QUALITY OF MATERNAL EXERCISE  metabolic & cardiopulmonary reserve promotion of normal glucose tolerance psychological benefits Maternal dose-response curve Fetal dose-response curve Threshold for maternal physical conditioning effects Fetal & Placental Adaptations Altered Fetal Development Altered Maternal Pregnancy Adaptation ? ? Sedentary lifestyle *

12. PRESCRIPTION FOR AEROBIC ACTIVITY DURING PREGNANCY FREQUENCY TWO OR LESS TIMES PER WEEK TOO LITTLE!!? Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

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

14. Among women of childbearing age, one potential pathway for obesity development is excessive pregnancy weight gain and post partum weight retention Siega-Riz et al. 2004. Nut Rev 62:S105-11 Pregnancy link to Obesity?????

15. Impact of maternal & child health on current obesity epidemic? Intervention times/promoting physical activity? before conception during pregnancy post partum early years of child’s life by mom’s influence & family life Prevention vs treatment??

16. Pregnancy is time when many women change to a healthier lifestyle improve eating habits quit smoking stop alcohol use moderate caffeine consumption think about active living Promotion of Active Living During Pregnancy

17. Stages of Change (Intentional health behaviour change – 5 stages): precontemplation (no intention) contemplation (considering a change) preparation (making small changes) action (actively engaging in change) maintenance (sustaining change over time) Bull et al. 2001. Med Sci Sports Exerc. 33:1147-56.

18. Health care providers promote active living throughout the life span including pregnancy Many women are interested in maintaining or improving pre pregnancy fitness levels as they become pregnant Traditional view has been replaced with active living and healthy lifestyle habits before, during and after pregnancy. Thus it is important that:

19. What do pregnant women want? Walking most popular activity Barriers to physical activity? Having children Lack of time Mottola & Campbell 2003. CJAP 28(4):642-653.

20. Effective promotion of active living during pregnancy depends on the extent and type of physical activity performed before conception, while taking into account the needs and wants of pregnant women throughout the three trimesters of pregnancy. How do we promote physical activity during pregnancy??

21. Education Programs that include: benefits of being active during pregnancy guidelines available for exercise during pregnancy (www.csep.ca) identified 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)

22. Perhaps community programs which facilitate and encourage walking, such as mall walking (combined with elderly), which would also overcome barriers to exercise, include child care, family walks including children May be successful in promoting active living and physical activity during pregnancy and postpartum!! (Active Living During Pregnancy, CSEP, 1999)

23. 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 – Why should we promote health in the postpartum? Improve women’s health and well-being in the immediate postpartum period, Reduce the risk of developing heart disease, obesity and other lifestyle-related diseases. – Better understanding of women’s health promotion in the 1 st postpartum year is an essential step in addressing this neglect in maternal health Walker LO, Wilging S. JOGNN 2000;29:229-236 Active Living Post-partum

24. Post-natal Exercise Muscle Conditioning (Active Living During Pregnancy, CSEP, 1999) Using baby for post-natal activities Using baby as resistance tool (carefully!!) Have fun interacting with baby when doing push- ups

25. 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

26. If maternal-child interaction is a significant initiating factor in the obesity epidemic, will the prevention of excessive weight gain in mother during pregnancy and subsequently less weight retention post-partum lead to lower rates of obesity in successive generations? Active living during pregnancy & post-partum??