PRE-Pregnancy Weight Loss And the Reducing Effect on CHILDhood Overweight - Aarhus

Ulla Kampmann Opstrup140 enrolled

Overview

The study is a single site parallel randomized controlled study. The study will be assessing the effect of a 10% pre-conceptional weight loss intervention vs a control group among healthy couples where the prospective mother is pregnant and overweight or obese (BMI 27-44.9 kg/m\^2). The couples in intervention group will receive dietitian counseling and participate in physical activity sessions to attain the 10% weight loss. The overall objective is to test whether a comprehensive pre-conceptional parental weight loss intervention effectively reduces the risk of offspring overweight, and adiposity and its complications compared to a control group.

The study is a single site parallel randomized controlled study. The study will be assessing the effect of a pre-conceptional weight loss intervention vs a control group among healthy couples where the prospective mother is pregnant (recruited at gestational age 18-36), overweight or obese (BMI 27-44.9 kg/m\^2), between 18-38 years and planning an additional pregnancy within the following 3 years. The investigators will recruit a total of 140 healthy pregnant couples who will be randomized 1:1 to either intervention or control, stratified according to maternal pre-pregnancy BMI and previous or present diagnosis of gestational diabetes. The couples in intervention group will receive dietary counseling by a dietitian from 3 months post-partum of the 1st child until birth of the 2nd child. The goal is to achieve a healthy lifestyle and a moderate weight loss of 10% according to pre-pregnancy weight during the first year. Hereafter, the couples will be guided in weight maintenance until pregnancy of the second child. During pregnancy the goal is to achieve a healthy weight gain. Couples in intervention group will also participate in physical activity sessions every 2nd week and advised to walk with moderate intensity at least 2-4 times a week for at least half an hour. The overall objective is to test whether a comprehensive pre-conceptional parental weight loss intervention effectively reduces the risk of offspring overweight, and adiposity and its complications compared to a control group. The 1st baby born before intervention is started will be the "index child" and the metabolic and anthropometric parameters of the 1st child will be compared to parameters of the second child to assess the effect of the parent's healthy lifestyle between the two pregnancies. The investigators hypothesize that parental weight loss intervention, initiated before conception, will facilitate lower parental insulin resistance, inflammation, body weight and adiposity, incretin responses and energy expenditure compared to usual care. For the offspring the investigators hypothesize that the intervention will reduce adverse pregnancy outcomes with a short-term reduction in the risk of being born large for gestational age with excessive fat mass and a long-term reduction in the risk of developing overweight or obesity as a consequence of both social (family approach) and biological (epigenetic modifications) pathways.

Interventions

Weight loss interventionBEHAVIORAL

Subjects will receive dietary counseling by a dietitian from 3 months post-partum of the 1st child until birth of the 2nd child. The mother (and father if overweight, BMI ≥25 kg/m\^2) will receive advice to provide a moderate caloric restriction (-500 to 1000 kcal/d) and power walk 2-4 times a week for a half an hour and attend physical activity sessions every 2nd week to attain a minimum weight loss of approximately 0,5-1,0 kg/week. The weight loss will last until a 10% weight loss (according to pre-pregnancy weight) has been achieved or until 1-year post-partum. If the subject has not achieved a weight loss of 10%, she or he will receive Very low-calorie diet (VLCD) until target weight loss is reached, though no longer than 8 weeks. After weight loss subjects will receive counseling to maintain weight loss and healthy weight gain during pregnancy until birth of the 2nd child.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 38 YearsHealthy volunteers:

Medical Language ↔ Plain English

Maternal inclusion Criteria: * Maternal pre-pregnancy BMI 27.0-44.9 kg/m\^2 * Maternal age range 18-38 years * Connected to Aarhus University Hospital as place of birth * Pregnant Paternal Inclusion Criteria: * Paternal pre-pregnancy BMI 18.5-44.9 kg/m\^2 * Paternal age range 18-55 years Parental Inclusion Criteria: * Couples (male and female) * Planning pregnancy within 3 years * Provided voluntary informed consent * Danish or English speaking * Intention to permit the planned offspring to participate in the follow-up study * Able to store biological samples from the offspring at home in the freezer in a box given by the study personnel Parental Exclusion Criteria: * Diabetes mellitus (Type 1 or 2) * Previous or present eating disorder * Allergy towards ingredients in the very low calorie diet products * Severe heart, liver or kidney disease * Conception by in vitro fertilization * Any medical condition or concomitant medication as judged by the medical responsible * Adherence to vegan diets or other diets interfering with the dietary guidelines in the study * Participation in other clinical trial that can affect the results of the current study * Engagement in elite sports or similar strenuous exercise ≥5 h/week at inclusion * Blood donation or transfusion within the past month before screening * Blood donation during the study * Inability or unwillingness to follow the study protocol and instructions given by the study personnel A detailed description of the exclusion criteria is given below: Medical conditions as known by the participant: * Diabetes mellitus (type 1 and 2) * History or diagnosis of eating disorder (e.g. restrained eating, disinhibition, emotional eating) * Any significant medical condition as assessed by the investigator (e.g. dysregulated thyroid disease or reproductive diseases) * Any significant psychiatric disorder (i.e. schizophrenia, bipolar disease or depression) as assessed by the investigator * Severe chronic heart, liver and kidney disease * Polycystic ovary syndrome with irregular cycle Medication: * Current use of medication or use within the previous three months with a potential to affect body weight or pregnancy as judged by the investigator (e.g. systemic corticoids) Personal/other: * Severe food allergies, food intolerances or dislike expected to interfere with the study, including allergy towards ingredients in the VLCD products * Engagement in elite sports or similar strenuous exercise ≥5 h/week * Blood donation or transfusion within the past month before screening * Planned blood donation for other purpose than this study during participation * Alcohol abuse, as judged by the investigator, within the previous 12 months * Drug abuse, as judged by the investigator, within the previous 12 months * Psychological or behavioral problems which, in the judgement of the investigator, would lead to difficulty in complying with the study protocol * Participation in other clinical trials within the past three months or intention to do so during the study, which are judged by the investigator to affect the present study * Unable to consume the interventional product for religious reasons, swallowing disorders, other physiological reasons or any other reasons for not being able to follow the recommended diet * Inability or unwillingness to give written informed consent or communicate with study personnel * Inability or unwillingness to follow the study protocol and instructions given by the study personnel * Illiteracy or inadequate understanding of Danish or English language. * Any other condition that judged by the investigator may interfere with the adherence to the study protocol

Outcomes

Primary Outcomes

Neonatal fat mass

Offspring's neonatal fat mass (grams) assessed by air displacement plethysmography (Pea POD)

Time frame: Collected within the first week of birth (strived <48 hours)

Difference in epigenetic changes in child 1 and 2

Cord blood from offspring will be collected at birth and stored at -80 °C until use. At the Department of Molecular Medicine AUH genomic DNA will be extracted from peripheral blood using standard methods e.g., QIAmp® Mini Kit (Qiagen, Germany). 1 μg of genomic DNA will be bisulfide converted using Illumina iScan (platform). The methylation level will be measured using Infinium MethylationEPIC DNA Analysis BeadChip (Array type) at Eurofins Genomics AS (Denmark) or similar methods. The stated required sample size (140 couples) is calculated based on the neonatal fat mass. As no other studies have performed methylation analysis using WGBS in similar cohorts, precise power calculations on epigenetic changes are impractical. However, since the EPICOM study found differentially methylated regions in only 20 cases and 20 controls using Illumina's 450K methylation assay, the power to elucidate epigenetic changes is considered sufficient in the planned study.

Time frame: Assessed at birth

Secondary Outcomes

Obstetrics outcome - length of gestational age

Length of gestational age

Time frame: Assessed at birth of both offsprings

Obstetric - medication use

Medication use during labor

Time frame: Collected from initiation of labor until completed birth of both offsprings

Obstetric - delivery mode

Delivery mode (rupture of membranes or premature contractions, vaginal, cesarean section, instrumental delivery, miscarriage and stillbirth).

Time frame: Collected at birth of both offsprings

Obstetric - pregnancy complications

Pregnancy complications e.g. miscarriage, abortion (induced and indication for abortion), hydramnios, gestational hypertension, preeclampsia, need for maternal corticosteroid treatment for fetal lung maturation, urinary tract infection) will be collected from medical record.

Time frame: Collected at gestational age (GA) 34-36 and after birth of both offsprings

Obstetric - Neonatal unit admissions

Neonatal unit admissions

Time frame: Collected at birth and until 12 months after birth of both offsprings

Obstetric - obstetrics complications

Obstetrics complications (e.g. preterm prelabour rupture of the membranes, shoulder dystocia, birth trauma (perinatal rupture), postpartum hemorrhage, maternal infections, maternal hospitalization).

Time frame: Collected at birth of both offsprings

Obstetrics - birth defects/abnormalities

Birth defects/abnormalities

Time frame: Collected at birth of both offsprings

Neonatal morbidities

Neonatal morbidity (e.g. major congenital malformations (ICD10 Q00-Q99 or requiring medical or surgical treatment), birth injury, respiratory distress, transient tachypnoea, neonatal hypoglycemia, systemic infections, admission to neonatal intensive care unit, number of admission days, hyperbilirubinemia), deaths.

Time frame: Collected at birth of both offsprings

Fetal and offspring growth - body weight

Fetal body weight will be measured with ultrasound during pregnancy and offspring body weight will be measured using an electronic scale.

Time frame: Collected from medical record during pregnancy, measured in gestational age (GA) GA34-GA36 via ultrasound in both pregnancies, at birth and 3, 12 and 18 months after birth of both offsprings

Fetal and offspring growth - length

Fetal length will be measured with ultrasound during pregnancy and offspring length will be measured using an infantometer as appropriate for measuring infant, baby and toddler length.

Time frame: Collected from medical record during pregnancy, measured in GA34-GA36 via ultrasound in both pregnancies, and measured at birth and 3, 12 and 18 months after birth of both offsprings

Fetal and offspring growth - abdominal circumference

Abdominal circumference will be measured with ultrasound during pregnancy and offspring abdominal circumference will be measured three times to the nearest 0.1 cm using a stretch-resistant measuring tape

Time frame: Collected from medical record during pregnancy, measured in GA34-GA36 via ultrasound in both pregnancies, and measured at birth and 3, 12 and 18 months after birth of both offsprings

Fetal and offspring growth - crown circumference

Crown circumference will be measured with ultrasound during pregnancy

Time frame: Collected from medical record during pregnancy, measured in GA34-GA36 via ultrasound in both pregnancies

Fetal and offspring growth - femur length

Femur length will be measured with ultrasound during pregnancy

Time frame: Collected from medical record during pregnancy, measured in GA34-GA36 via ultrasound in both pregnancies,

Fetal growth - fractional limb volume

Fractional limb volume will be measured with ultrasound during pregnancy

Time frame: Collected from medical record during pregnancy, measured in GA34-GA36 via ultrasound in both pregnancies,

Offspring growth - BMI z-score

Offspring body mass index (BMI) z-score (BMI adjusted for age and sex).

Time frame: Collected at birth and 3, 12 and 18 months after birth of both offsprings

Offspring growth - weight for gestational age

Weight for gestational age. Measured as percent of normal weight related to gestational age.

Time frame: Collected at birth and 3, 12 and 18 months after birth of both offsprings

Offspring growth - large for gestational age

Large for gestational age. Prevalence of infants being large for gestational age (LGA).

Time frame: Collected at birth of both offsprings

Offspring growth - small for gestational age

Small for gestational age. Prevalence of offspring being small for gestational age (SGA).

Time frame: Collected at birth of both offsprings

Offspring growth - apgar score

Apgar score (0-10). The higher the score, the better health condition of the offspring)

Time frame: Collected at birth of offspring of both offsprings

Offspring growth

Offspring circumference (thigh and upper arm) and skinfold (triceps, subscapularis and suprailiac). Circumferences will be measured to the nearest 0.1 cm using a stretch-resistant measuring tape and skinfolds are measured to the nearest 0.02 cm using a caliper to lightly pinch the skin and the underlying fat.

Time frame: Collected at birth and 3, 12 and 18 months after birth of offspring.

Offspring growth - body composition by the POD system

Offspring fat free mass (g) and fat mass (g) will be assessed by air displacement plethysmography using the POD system (Pea POD for 1-8kg)

Time frame: Collected within the first week of birth and 3 months post partum in both offsprings

Offspring blood pressure

Offspring blood pressure (diastolic and systolic blood pressure) will be measured three times after 10 minutes rest using an automated device placed on the arm and in direct contact with the skin.

Time frame: Collected 12 and 18 months after birth of both offsprings

Offspring heart rate

Offspring heart rate will be measured three times after 10 minutes rest using an automated device placed on the arm and in direct contact with the skin.

Time frame: Collected 12 and 18 months after birth of both offsprings

Offspring growth - self-reported body weight

Self-reported body weight

Time frame: 18 months after birth the study staff will make an annual follow-up phone call to the parents to collect information about the offspring's self-reported body weight until the offspring is 18 of age

Offspring growth - self-reported height

Self-reported height

Adult weight

Adult body weight is measured to the nearest 0.1 kg using a calibrated scale

Time frame: Intervention: each visit throughout study (GA34-36 of 1st child to 18mo. after birth of 2nd child). Control: In GA34-36 in both pregnancies, at study visits (3, 12 and 24mo. pp) and follow up visits (3, 12 and 18 months pp of 2nd child)

Adult Height

Adult height will be measured to the nearest 0.5 cm using a wall-mounted stadiometer.

Time frame: Collected in GA34-GA36 in index pregnancy

Adult BMI

Calculated as weight (kg)/height(m)\^2

Time frame: Collected in GA34-36 in 1st pregnancy, study visits 3, 12 and 24mo. pp after 1st child, GA34-36 in 2nd pregnancy and at follow up vist (3, 12 and 18mo. pp of 2nd child).

Adult anthropometric

Waist- and hip circumference will be measured to the nearest 0.1 cm. During pregnancy and at birth the waist of the female will not be measured.

Adult blood pressure

Blood pressure (diastolic and systolic blood pressure) will be measured three times with two minutes apart in right arm after 15 minutes rest using a validated automatic device. The reading is recorded to the nearest 1 mmHg.

Time frame: Collected at GA34-36 in 1st pregnancy, study visits 3, 12 and 24 months pp. of 1st child, GA34-36 in 2nd pregnancy and 3 months pp after 2nd child

Adult heart rate

Heart rate will be measured three times with two minutes apart in right arm after 5-10 minutes rest using a validated automatic device. The reading is recorded to the nearest 1 beats/minute for heart rate

Time frame: Collected at GA34-36 in 1st pregnancy, study visits 3, 12 and 24 months pp. of 1st child, GA34-36 in 2nd pregnancy and 3 months pp after 2nd child

Adult resting metabolic rate

Resting metabolic rate (calories/24-h) will be measured by indirect calorimetry using a ventilated hood system. Participants will lie in the supine position and rest for at least 30 min before measurements commence. The measurement will last for 20 min.

Time frame: Collected at study visit 3, 12, and 24 months pp after 1st child.

Adult resting respiratory quotient + substrate

Resting respiratory quotient (RQ), will be measured by indirect calorimetry using a ventilated hood system. Participants will lie in the supine position and rest for at least 30 min before measurements commence. The measurement will last for 20 min. Lipid, glucose and protein oxidation will be estimated.

Time frame: Collected at study visit 3, 12, and 24 months pp after 1st child.

Adult medication use

Use of medication will be collected throughout the study and for each medication the start date, stop date or continuing, form and indication will be noted in appropriate form.

Time frame: Collected at GA34-GA36 in 1st pregnancy, study visit 3, 12 and 24 months pp of 1st. child

Offspring medication use

Use of medication will be collected throughout the study and for each medication the start date, stop date or continuing, form and indication will be noted in appropriate form.

Time frame: Birth, after 3, 12, and 18 months after birth of both offsprings

Adult reproduction - Time to pregnancy

Duration of time to conception defined from selfreported time point they started to try get pregnant to registration of pregnancy. The time of conception will be calculated from the ultrasound scan in week 12

Time frame: Registration of 2nd. pregnancy (up to tree years from birth of 1.st. child)

Adult glucose metabolism (OGTT)

3-h oral glucose tolerance test (OGTT) will be performed at with 75g of glucose dissolved in 250 ml of water and added 1 gram of paracetamol. Blood will collected for measurements of blood glucose, hormones (insulin, C-Peptide, glucagon), paracetamol, glucagon-like-peptide-1 (GLP-1), Glucose insulinotropic polypeptide (GIP) and metabolites (FFA). Blood samples will be drawn at time 0, 15, 30, 45, 60, 90, 120 and 180 min

Time frame: Performed at study visits 3, 12 and 24 months pp of 1st. child

Adult Oral Glucose Tolerance Test (OGTT) during pregnancy (only female)

OGTT performed during pregnancy according to the screening guidelines for GDM will be obtained from the mother's medical journal in both pregnancies.

Time frame: Collected in GA28 of 1st and 2nd pregnancy (performed after risk score at gestational age~20 and ~28 or only ~28)

Placenta - weight (gram)

Placenta will be weighted after birth

Time frame: Collected at birth of both offsprings

VO2-max adult - cardiorespiratory fitness

The VO2-max test will be performed as an incremental exercise test on a bicycle ergometer.

Time frame: Collected at study visit 3, 12 and 24 months pp after birth of 1st child

Cardiac function offspring - Left ventricular and right ventricular morphology

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of Interventricular septal thickness diastole and valve- and chamber dimensions will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - left centricular ejection fraction

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of left ventricular ejection fraction will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - fractional shortening

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of fractional shortening will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Systolic function, strain

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of strain will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Systolic function, strain rate

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of strain rate will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - TAPSE and RV fractional area change

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of TAPSE and RV fractional area change will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Diastolic function, left ventricular E/A-ratio

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of left ventricular E/A-ratio will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Diastolic function, tissue velocities (E', A', S')

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of tissue velocities (E', A', S') will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Diastolic function, strain

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of strain will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Overall cardiac function

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of Myocardial performance index (MPI) and cardiac torsion will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Pulmonary artery acceleration time

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of Pulmonary artery acceleration time will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Pulmonary artery pressure

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of Pulmonary artery pressure will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cardiac function offspring - Persistent ductus arteriosus (PDA)

ECG and echocardiography will be performed according to standard imaging protocol. Assessment of PDA open or closed and PDA shunt will be done.

Time frame: Collected at birth and at 12 months follow up visit after birth of each child

Cord blood - Telomore length

Cord blood will be drawn immediately after birth and analysed. Blood will be analyzed for Telomore length.

Time frame: Collected at birth of both offsprings

Cord blood - pH

Cord blood will be drawn immediately after birth. pH will be assessed.

Time frame: Collected at birth

Cord blood - Epigenetics

Epigenetics analyses from whole blood. Will be analysed for methylation changes. metabolomics and exosome.

Time frame: Collected at birth of both offsprings

Adult body composition by DEXA scan

Lean mass (g), fat mass (g), abdominal fat (g), visceral fat (g) assessed by a Dual-energy X-ray absorptiometry (DEXA) -scan .

Time frame: Collected at study visits 3, 12 and 24 months pp. of 1st child

Adult bone markers by DEXA scan - bone mineral content

Bone mineral content (g) assessed by a Dual-energy X-ray absorptiometry-scan.

Time frame: Collected at study visits 3, 12 and 24 months pp. of 1st child

Adult bone markers by DEXA scan - bone area

Bone area (cm\^2) assessed by a Dual-energy X-ray absorptiometry-scan.

Time frame: Collected at study visits 3, 12 and 24 months pp. of 1st child

Adult bone markers by DEXA scan - bone mineral density

Bone mineral density (g/cm\^2) assessed by a Dual-energy X-ray absorptiometry-scan.

Time frame: Collected at study visits 3, 12 and 24 months pp. of 1st child

Adult blood sample - glucose

All blood samples will be collected by venous puncture in the antecubital vein after an overnight fast from at least 10 pm the night before. Samples will be analysed for glucose