Maternal Obesity & Mobile Technology Hora Soltani Professor of Maternal and Infant Health Health & Social Care Research Centre

Multi-disciplinary Research Team Clinical team (Doncaster)

Technology & Design (UCHD)

Carolyn Garland & Alison Williams (Maternal obesity (Monday) Clinic coordinator )

Professor Andrew Dearden Helena Sustar (Design) Mark Fisher (Design)

Health & Social Care Research Prof Hora Soltani Alex Scott (Nutritionist/research assistant)

(PPI: Maternity user group rep.) Naomi Watkins & Jenna Feeney

Health Psychology Dr Penny Furness Prof Maddy Arden (Health psychologist) Acknowledgement : Dr Fazilatur Rahman, Dr Sally Atkinson & Lindsey Reece, Anne Pridgeon (Dietician), Rob Bell (Technology), Kerry McSeveney (Sociolinguist)

Introduction • Obesity (BMI≥30) is a major public health challenge • It is predicted that more than half of the adult population to be obese by 2050 (McPherson 2007) with an estimated cost of £9.7 billion to the NHS • 20% of UK pregnant women are obese

Pregnancy & Obesity Obese pregnancies and excessive GWG are associated with increased risk of mortality for: • mothers: 50% of total maternal mortality was associated with OW&OB and

• babies: Obesity almost doubles the risk of perinatal mortality (CEMACH 2007 & Gardosi et al BMJ 2013)

Cont.

Pregnancy & Obesity Obesity & Excessive GWG are associated with complications:

Short term: • Macrosomia, shoulder dystocia & alnomalies,.... • CS & instrumental birth • Gestational Diabetes, Raised BP & infection • Longer Post Natal stay • ↑Resource & cost implications for NHS (x5 greater) Long term: • Risk of further obesity in mothers and their offspring

Existing evidence • Combination of exercise, dietary & mixed interventions during pregnancy can be effective in GWG management without adverse outcomes (Thangaratinam 2012)

• Existing evidence is of a poor quality & UK based research in this area is needed (NICE 2010)

• To optimise effectiveness, research should focus on novel modes of intervention such as telephone and internet-based programs (Sarwer 2006)

Use of Mobile Technology for Weight loss • Systematic reviews of Mobile technology based trials in general public report relatively consistent success among studies in achieving significant weight loss (Heron 2010, Rao 2011; Wei 2011, Bacigalupo 2011) • None of the existing/new studies used Mobile technology in managing GWG during pregnancy (HELP, LIMIT & UPBEAT) except for one pilot trial (Pollak 2014)

Justification • Mobile technology (e.g. TM) has the advantage of – being widely accessible :131 subscriptions/100 people in UK (WHO 2011) – providing remote, continuous support via motivational & informational messages – optimising access and reducing cost (Agras 1990) – overcoming challenges associated with the stigma

Aims and Objectives Specific MOMTech project objectives were to: • Explore the need for additional maternal obesity support services/use of mobile technology • Designing a platform for self-management mentoring & support of obese pregnant women • Explore usability/feasibility of a text messaging based complex intervention in managing GWG in obese pregnant women

Setting • Doncaster provides a unique maternal obesity (Monday) clinic • An award winning initiative, providing support and nutritional information for women with BMI≥40 (usually 2 visits)

Design • Mixed methodology, divided to: – Phase 1 (Supported by EFL & CLAHRC-TaCT): • stage a. focus groups of women, midwives and obstetricians to identify user requirements, type of media • stage b. explore & develop system design, content, modality, frequency & intensity of messages, development of case stories • stage c. verification of scenarios, prototype demonstration via (cyclic) evaluation workshops (women, midwives & doctors)

– Phase 2 (funded by Bupa): Feasibility testing to assess recruitment pattern, compliance & acceptability of the intervention

Findings 1 • Women need unambiguous advice/support re diet & exercise • Women were particularly enthusiastic about the use of text messaging as being a tool in modernising service provision, for being motivating and reducing the sense of isolation • Midwives were concerned about the content of the messages to be personalised, sensitive and of the right tone 1. SoltaniH , Furness P, McSeveny K, Arden M, Garland C, Dearden A. (2012) Women's and health professionals' perspectives on the use of mobile technology in support of maternal obesity service provision". Journal of Obesity. doi:10.1155/2012/835464. 2. Furness P, McSeveny K, Arden M, Garland C, Dearden A, Soltani H. (2011) Maternal Obesity Support Services: A qualitative study of the perspectives of women and health care providers'. BMC: Pregnancy and Childbirth. 11:69. Available from: http://www.biomedcentral.com/1471-2393/11/69

Findings 2: Current products • in collaboration with women and HCP a demoprototype including: – a series of text messages tailored to specific diet and physical activity behaviour goals (with supporting diaries) – within the constructs of goal setting, self monitoring, reviewing behaviours & overcoming barriers – a platform for delivering the TM service

• Process: Participants received two daily text messages (activity and dietary goals), supported by 4 appointments with the midwife (2 consultations & 2 follow ups):

Dearden A, Arden M, Fisher M, Furness P, Garland C, McSevenny K, Sustar H, Soltani H. (2012) Midwives, Obesity and Mobile Technology (MOMTech): a User Centred Healthcare Design. Fourth International Conference on Human Computer Interaction. India April 2012-full paper.

Platform for TM delivery

•Consultation 2 (16-18 wks): o Goal setting & Choosing specific editable TM according to dietary and Exercise goals (specific, barriers, reminders, recipe links) o Self monitoring diaries • Followed at 28 & 36 wks routine appts and by offering monthly telephone contacts to change TM/goals according to their needs

Registration

Consultation 1 (14-16 wks): o Consent & Registration & Information/discussion o How to stop o Choosing generic TM from a starter menu (frequency & timing & type) o Food& Activity diaries

Findings 3a: feasibility study 34 met inclusion criteria/were invited (July 2013-Jan 2014)

6 declined (CG)

12 didn't attend (8

changed their minds (CG) & 4

28 agreed verbally to participate

16 consented

developed complications (excluded)

2 drop outs (1 moved out of area/1

withdrew (CG)

14 continue d (IG)

Characteristics

Intervention Comparison group M (SD) group M (SD)

Age (yr)

29.1 (5.4)

31.7 (5.8)

Booking BMI

36.6 (4.5)

37.0 (5.4)

n (%)

n (%)

White British

14 (100%)

15 (100%)

Nulliaparous

5 (36%)

1 (7%)

Married

6 (43%)

5 (33%)

Employed

11 (78%)

9 (60%)

Smokers

4 (27%)

5 (33%)

CG: comparison group [n=15] Intervention group [n=14]

Findings 3b: feasibility study Characteristics

Intervention group M (SD) [range]

Comparison group M (SD) [Range]

Gestational weight gain (kg)

5.6 (4.6)

9.7 (7.2)

Gestational age

39.3 (1.5) [36–41]

39.2 (1.8) [34*–41]

Birthweight (gr)

3598.7 (532.8) [2785-4390]

3453.2 (525.1) [2120*–4200]

GWG in relation to IOM guidelines

n (%)

n (%)

GWG < 5 kg

7 (50%)

4 (33%)

GWG 5 kg to 9 kg 3 (21%)

2 (17%)

GWG > 9 kg

6 (50%)

4 (29%)

Summary • Uptake: 47% (16/34) • Compliance: 88% (14/16) • A small sample size but compared to the comparison group, participants had: – lower mean GWG than the comparison group – few exceeded the Institute of Medicine’s upper limit of 9 kg GWG for obese women. • Qualitative interviews: – were positive – suggestions made on the number of text messages, diaries & consultation logistics (e.g. no monthly contact by the midwife was needed)

Conclusion Using a text messaging based complex intervention for managing gestational weight gain is: • feasible • acceptable by women

• this needs to be further investigated in a multicentre large trial

Publications & Future plans – 4 publications and 2 poster presentations: o Soltani H , Duxbury AM, Arden M, Dearden A, Furness P, Garland C. (2015) Maternal obesity management using mobile technology: A feasibility study to evaluate a text messaging based complex intervention during pregnancy. Journal of Obesity. http://dx.doi.org/10.1155/2015/814830

o Poster: Development of a complex intervention in managing “Maternal Obesity” using “Mobile Technology” (MOMTech) ECO Liverpool 2013 Obesity Facts, European Journal of Obesity. Obes Facts 2013;6(suppl1)pp154

o Submission to HTA-NIHR in collaboration with Florence (external TM company) o Collaborating with Hull University/Trusts in further development and future submissions

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