Maternal overnutrition can have long-lasting consequences on fetal development. The Healthy Eating-Healthy Child Task Force needs to allocate more funding toward research on and awareness of the importance of healthy maternal exercise and nutrition to reduce the potential for epigenetic changes that may lead to predisposed type 2 diabetes mellitus and obesity among children. A comprehensive pilot study that expands upon past research with an increase in hours of exercise and weeks of exercise amongst the experimental cohort of pregnant women is warranted to note how an increase in exercise, compared to past studies, coupled with healthy eating habits over time, lessens the susceptibility of pregnant women to the development of gestational diabetes mellitus (GDM) and thereby epigenetic changes in children. In addition, a public awareness campaign in all DC wards, targeted toward pregnant women and those hoping to get pregnant, is necessary to increase understanding of the effect of the intrauterine environment on a fetus.
Problem statement
Abnormal intrauterine environments are a public health concern receiving relatively little attention within the health sphere, especially in Washington, DC, which has over 52,000 residents currently living with diabetes.9 Overnutrition and physical inexertion in mothers often leads to the development of obesity and/or GDM (an inability of the body to tolerate sugars and starches), which increase glucose levels in the fetal environment and can trigger gene expression, or epigenetic, changes that negatively impact a developing baby.3,6,8 Recent findings have shown that offspring of mothers with obesity or GDM may be epigenetically predisposed to developing long-term metabolic problems, including type 2 diabetes, that could potentially lower their health-related quality of life, subject them to stigmatization, and lead to other medical issues (comorbidities) over time.
The Healthy Eating-Healthy Child Task force needs to devote resources toward researching and raising consciousness of the impact of diet and exercise in preventing abnormal intrauterine environments in pregnant mothers in the DC area. Because all ethnicities are subject to gaining weight, and thereby to the development of GDM and its consequences on a fetus4, research needs to include a diverse array of subjects and public awareness campaigns need to be instigated in all DC wards. The DC community will benefit through these interventions due to lessened health costs resulting from diabetes/obesity/metabolic disorders in the future, and will maximize economic output of its future residents, who will have lessened epigenetically-predisposed susceptibilities to these health concerns. Through interventions with pregnant women, public health professionals and researchers can help to break the sequence of health events that predispose children to metabolic diseases across generations.
Evidence and Potential Solutions
Insulin delivers glucose, which supplies energy, to cells. A hyperglycemic environment in utero leads to hyperinsulinism and thereby escalates fetal growth. 3,6,8 This abnormal environment has been shown to modify DNA expression, leading to birth defects, metabolic diseases, and the development of type 2 diabetes among children.3,6,8 Medication to regulate glucose and insulin levels has been utilized to prevent GDM and is a potential solution to resulting epigenetic changes, yet through proper diet and exercise, the need for medication—which needs to be injected, can be misused, and is costly—is lessened.2
Sedentary, aerobic exercise, such as cycling, for at least 3 hours per week among overweight and obese pregnant women has a significant correlation with decreased rates of GDM.7 Furthermore, this type of physical activity has been linked to reduced maternal gestational weight gain during the second trimester, lowered rates of preterm birth, and reduced fetal weight.10 Maternal diets also influence susceptibility to GDM; a high intake of animal fat, commonly found in dairy products and junk food, and cholesterol is associated with increased risk of GDM.1 Pregnant women who adhere to a Mediterranean diet have also been found to have a lowered risk of developing GDM.5 Although diet and exercise have been found to lessen risks of GDM and therefore fetal metabolic problems later-in-life, these programs and styles of living are often costly, inconveniently located, or unfeasible for women of lower socioeconomic status to participate in or purchase.
Despite the drawbacks of interventions focused on the influence of diet and exercise at improving long-term maternal health, the overall advantages of healthy eating and physical activity (in comparison to interventions via medication) should compel the Healthy Eating-Healthy Child Task force to propose a pilot study researching the impact of diet and exercise on maternal health and the development of GDM amongst DC pregnant women. This pilot study would precede the development of diet and exercise programs for DC’s pregnant residents, provided that findings confirm their success at reducing negative epigenetic fetal changes. In addition, a DC public awareness campaign should be devised to raise awareness of the issue and to reach pregnant women who are not involved in the pilot study.
Recommendations
In order to combat the rise of GDM, the Healthy Eating-Healthy Child Task Force should implement a pilot study to observe the effects of diet and exercise on pregnant mothers in the Washington DC metropolitan area. In addition, a public awareness campaign should be devised to educate not only expectant mothers, but also to inform women who plan to get pregnant, of the influence of the intrauterine environment on fetal development and metabolism.
Expectant mothers in their first trimester should be recruited for the experimental research study and, upon meeting standard inclusion criteria, complete the informed consent process to participate. A total of 40 experimental subjects should be matched, as closely as possible, by age, ethnicity, and stage of pregnancy. Half of the subjects will occupy the control group of the experimental paradigm: they will receive no dietary supplements other than a placebo pill and will be asked to maintain their respective normal exercise habits. The other half of matched subjects will receive weekly, low-cost, Mediterranean-style meal plans centering on healthy eating habits, with an emphasis on a diet low in animal fat, white bread, red and processed meats, and processed foods. Participants will log their adherence to these meal plans. In addition, this matched cohort will participate in a cycling exercise program, 3 times a week, for a minimum of 5 hours per week. Subjects in each experimental cohort will receive standard prenatal care from a primary care provider, and their weight, insulin levels, and glucose levels will be monitored until 38 weeks of gestation. The development of GDM among participants in each experimental cohort will be assessed to examine the effects of diet and exercise on maternal health.
Researchers should place materials advertising the study in maternity wards and obstetrics practices in the DC area; furthermore, they should contact local medical professionals involved in these clinics to request that they alert and inform patients of the study during their check-ups. In theory, this approach to study recruitment will enable researchers to gain a diverse population of subjects and, therefore, further insight regarding how age, socioeconomic status, and race influence the impact of diet and exercise on maternal health.
A public awareness campaign should be devised to create and distribute informational handouts, in lay terms, on the importance of healthy diet and exercise habits for pregnant women and their role in preventing GDM in the mother and epigenetic changes that may have long-term consequences for the fetus. These handouts should be delivered to and made prominent in DC hospitals, health clinics, medical practices, family planning institutions, and pregnancy centers in all wards. In addition, public service announcements should be devised for social media and local television advertisements, as many young mothers may be more likely to be exposed to health information via media outlets.
Funding for the pilot study should be requested through grant proposals submitted to the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (~$100,000 for the pilot study). To fund the public awareness campaign (~$50,000), it is recommended that the Healthy Eating-Healthy Child Task Force reach out to sponsors such as Gerber, the American Diabetes Association, and the DC Department of Health for support.