Dr Sam Manger 0:00   

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

Dr Susan de Jersey 0:20   

I don’t like to assume things when it comes to consumers or health professionals, because we really do all have a very different story, expectations, backgrounds, and there is, unfortunately, still some messaging within society that women should eat for two and what we know is that there is wide individual variation in changes in the energy cost of pregnancy. 

Dr Sam Manger 0:44   

Hi, I’m Dr Sam Manger, a GP, and your host of this series, The Clinician’s Guide to the First 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

Prevention across the first 2000 days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started. 

For today’s episode in antenatal care, we are deep diving into preventative health behaviours when pregnant, and to do so, I’d like to welcome Dr Kassia Beetham and Dr Susan de Jersey. Kassia is a senior lecturer at the Australian Catholic University and an experienced Exercise Physiologist with research focusing on pregnancy and postpartum exercise and physiology.  

Associate Professor Susan de Jersey is the Strategic Lead for Healthier Pregnancies in the Preventive Health branch of Queensland Health and is an Advanced Accredited Practicing Dietitian. Thank you both for joining me.  

Dr Kassia Beetham 1:55   

Thank you.  

Dr Sam Manger 1:55   

So Kassia, let’s start with you around the concepts of exercise, movement, clearly your area of expertise, what physiological changes occur during pregnancy that can impact exercise and movement? 

Dr Kassia Beetham 2:06   

Pregnancy is an extraordinary time in a person’s life. Nearly every system in the body has significant changes, and many of these changes influence exercise, our response to exercise and how we should exercise. A couple of key changes are in the cardiovascular system; the blood volume doubles during pregnancy, and this has effects on heart rate, metabolically, how hard you’re working, your resting heart rate rises throughout pregnancy until the day you give birth.  

Musculo-skeletally, there is some really big changes, as you can imagine, over a short period of time. You have… your centre of mass is moving forward with your baby growing in front of you, so that significantly changes your posture, and you adapt a sway back position where your pelvis tilts under and your back leans backward to maintain that midline. And that sudden change in your musculoskeletal system has big implications for pelvic girdle pain. We can try and reduce injuries and pain from these naturally occurring changes through exercise.  

Dr Sam Manger 3:07   

And what are some of the changes that occur to the soft tissues, like the ligaments and the tendons and things like that? Because, as you said, the pelvic girdle can change, and that can be a common source of discomfort for women. 

Dr Kassia Beetham 3:16   

There’s many key hormonal changes that occur during pregnancy, one of the key hormones that influences how your body moves is an increase in relaxin. It’s a hormone that relaxes your ligaments to ultimately allow for an increase in the birth canal for the baby to go through during delivery, so that can have implications for musculoskeletal injuries and pain, and it can be a cause of a common condition in pregnancy called sacroiliac joint pain. If we can strengthen the muscles around these joints, we can try and reduce some of the pain associated with these conditions. And it’s also important to be careful not to over stretch during pregnancy, because we do have those loose ligaments, and we don’t want to cause any sudden, acute injuries like dislocations. 

Dr Sam Manger 4:03   

So, on that point around things that we should be cautious of when we’re advising, are there any specific exercises or movements that should be avoided and does that change? Or at least, maybe not avoided, but caution applied to and does that change during the different trimesters? 

Dr Kassia Beetham 4:18   

One of the only key movements to avoid as pregnancy progresses is lying supine in the third trimester, because the weight of the baby can compress the blood vessels and cause a reduction in blood pressure. There are a whole range of other ways you should be modifying your exercise as well, but it’s really dependent on the person and how they’re traveling in their pregnancy. But certainly, there are modifications that would need to be done to movements and exercises to make sure they’re safe, but the big one is not lying on your back in the third trimester. 

Dr Sam Manger 4:49   

And are there some core principles around how we might modify movement when we’re thinking about health professionals providing advice to women around movement? What are some key components there? 

Dr Kassia Beetham 5:01   

So, the biggest issue with women exercising in pregnancy is the misinformation that they’re receiving from the world around them, and that’s from people within their close network, their friends and family, social media, and also their healthcare professionals. So, the biggest advice I would give to healthcare professionals working with pregnant women is to go to the Australian Physical Activity Guidelines for pregnancy and use that as a base for providing advice. So those guidelines are based on recommending exercising at a moderate intensity and also doing strength training twice a week is really important as well. 

Dr Sam Manger 5:37   

So, they’re not too different from the general physical activity guidelines? 

Dr Kassia Beetham 5:41   

They’re not, they’re identical. And I hope that in the future we will see some trimester specific guidelines, because we do know there’s such a big change in physiology as pregnancy progresses, but at this stage, they are very similar to the adult guidelines.  

Dr Sam Manger 5:54   

Excellent, well that’s convenient. And so, you mentioned strength training there, resistance training. So clearly, that’s safe and recommended. 

Dr Kassia Beetham 6:00   

Yeah, definitely. It’s really important to help prepare the body for birth. It reduces the risk of injury. It can improve mental health. So, strength training is not only safe, but it really should also be done by most pregnant women at least twice a week.  

Dr Sam Manger 6:17   

And you mentioned there around some of the benefits it may have. So, there’s the physical health benefits and the mental health benefits. Does it actually impact labour and delivery outcomes? 

Dr Kassia Beetham 6:25   

Exercise in general, not just strength training, but aerobic training as well, has been shown to reduce the first stage of labour and subsequently, that means there’s a reduced incidence of instrumental delivery as well as caesarean sections. There was also a systematic review meta-analysis published recently that looked at vigorous intensity exercise and found that the women who did vigorous intensity exercise up to the third trimester actually had a longer gestation and a reduced risk of prematurity.  

Dr Sam Manger 6:53   

Excellent. That’s very good to know. It’s lovely having experts in these podcasts, because we can pick many questions. But what sorts of signs could be red flags, so we’re talking about what we can encourage, but on the flip of that, are there any red flags we should be advising pregnant women around that let us know if this happens, so we can safety net? 

Dr Kassia Beetham 7:12   

Yeah, there’s some key red flags to look out for, and a lot of them are related to acute cardiovascular conditions, things like heart failure and pre-eclampsia. So, we’d be looking at things like chest pain that persists. We would be looking for shortness of breath that continues even after stopping exercise. Severe headaches can be another sign of very high blood pressure, any leakage from the vagina. So, any sort of discharge or blood should be a reason to stop exercise immediately and seek healthcare advice. 

Dr Sam Manger 7:34   

Very good, thank you. And Susan over to you! There are various recommended supplements to take during pregnancy. What’s your advice around these supplements and should women continue throughout their pregnancy and after? 

Dr Susan de Jersey 7:55   

Yeah, so at the moment, the only recommended supplements to take during pregnancy are iodine and folic acid. So, iodine is recommended to be taken throughout the whole pregnancy, so starting from about a month prior to conception and continued throughout pregnancy. Folic acid is recommended to start a month prior to conception and then continue to at least three months. There’s no widespread recommendation to continue folic acid beyond that first sort of three-month period. Folic acid and folate, which is found within food sources, is a key nutrient that prevents neural tube defects, and so the neural tube, by those three months has closed. So, there’s not thought to be additional benefit beyond that first three-month period. There are some particular conditions where higher doses of folic acid and longer durations may be recommended, such as women who have diabetes prior to pregnancy, and some medications might impact on…on that as well. So, it is worthwhile women talking with their doctor about what should be continued and at what dose.  

Beyond that, there are lots and lots of multi vitamins available for pregnancy. And what we need to remember is that within these multivitamin preparations, there is a range of bioavailability, so they’re not all absorbed the same. And so, as a standard recommendation, we don’t need for women to consume a multivitamin throughout their pregnancy unless they have been advised to do so. 

Dr Sam Manger 9:31   

And you mentioned iodine as well there. So folic acid for neural tube defects. What’s the iodine for? 

Dr Susan de Jersey 9:38   

So, iodine is really important for growth and development, particularly brain development, and historically, iodine was used as a sanitiser in milk production, and so we didn’t necessarily have a problem with iodine intake in our diets. But what’s happened as sanitisation processes have changed, our soils have become a little more deficient in. It’s recognised that these additional iodine requirements to support growth and development of a growing foetus can’t be met just by food sources alone. 

Dr Sam Manger 10:08   

And what are the doses you mentioned with folic acid? It depends on certain other comorbidities, and yes, they should be looked up too, but as a standard dose of folic acid and a standard dose for iodine, what are we aiming for? 

Dr Susan de Jersey 10:19   

The recommendations for the supplement of iodine is 150 micrograms, and the folic acid, as a standard recommendation, is between 400-500 micrograms.  

Dr Sam Manger 10:31   

Excellent. Thank you. And are there any other nutrients, whether it’s macro or micro, that we need to be very conscious of as pregnancy progresses, or we need to consider increasing as pregnancy progresses? 

Dr Susan de Jersey 10:41   

Most micronutrient recommendations or needs increase during pregnancy. It depends on the particular nutrient, but it can range from between 10% and 50%. So, iron is probably one of those micronutrients that does increase quite substantially, by about 50% but really, the human body is amazing in that there are many, many metabolic adaptations that happen across pregnancy to support the body getting these extra nutrients. So, things like slowing down of gut transit time to allow a greater time for the body to absorb nutrients within food, a woman obviously stops menstruating during pregnancy, which supports more retention of iron within the body from food sources. So, it’s not recommended to routinely supplement with iron unless somebody is identified as being deficient. 

Dr Sam Manger 11:30   

Very good. And are there any foods which really comes into that sort of early part of pregnancy that we… that should be avoided? You know, they often talk about soft cheeses and uncooked meat and those sorts of things. 

Dr Susan de Jersey 11:39   

What we know is that women are often told early on all of the things that they can’t eat during pregnancy, and there is quite a big focus on what women shouldn’t eat, and less of a focus on what they should eat. We know that our food modelling does support women being able to achieve micro nutrient recommendations, largely with food, but with pregnancy being a state of immunocompromised to a certain degree, there are particular foods, from a food safety point of view, that should be limited or avoided or making adaptations to perhaps make them safer. So particularly soft cheeses, premade salads in a salad bar, key things that should be avoided, deli meats are another one that’s pretty common, but most foods with some level of adaptation can be consumed during pregnancy. So, I’m really hesitant to focus on all of the things that women should not eat and really try and promote what they can eat.  

Dr Sam Manger 12:34   

What should we be recommending? How can a non-dietitian professional support a woman to eat healthier? What are the sort of core constructs of recommendations there. 

Dr Susan de Jersey 12:42   

So they’re not largely different from the general population in that we want to promote a balance across all of the five food groups, focusing on fruit and vegetables and whole grain breads and cereals, balancing intakes of those across the day sources of lean meat and protein and plant based proteins, as well as dairy products, and focusing on much more of those unprocessed foods as much as possible.  

Dr Sam Manger 13:08   

Excellent. Whole foods, very good. And so, if we assume that health professionals are aware that women don’t need to “eat for two” in pregnancy, how do we support women who report a larger appetite in pregnancy? Because that can be part of it. 

Dr Susan de Jersey 13:21   

I don’t like to assume things when it comes to consumers or health professionals, because we really do all have a very different story, expectations, backgrounds, and there is, unfortunately, still some messaging within society that women should eat for two and what we know is that there is wide individual variation in changes in the energy cost of pregnancy. 

Historical data sort of tells us that the energy cost of pregnancy may increase between 15 and 25% so we don’t need a large amount of extra food, but recognising for some women, the hormonal changes that we’ve sort of spoken about happening may increase appetite and appetite dysregulation. Another not uncommon scenario is women who experience nausea that settles with eating and that can present a really challenging time. And those are the things where, I think, on an individual basis, identifying what the particular challenge is. Is it driven by that nausea, needing something in your tummy to settle it, and identifying what sorts of foods might be tolerated in that situation. Or is it perhaps some of that hormonal dysregulation, poor sleep can impact on appetite and focusing on how we can identify what foods in that particular individual scenario might be better tolerated. So, focusing on fruit and vegetables, the whole grain breads and cereals that might help with increasing satiety.  

Dr Sam Manger 14:48   

And you mentioned dysregulated appetite there, so, can you break that down a bit for us? What do you mean by that? Do you mean the influence of other stresses, psychological and physiological, on the person, causing a change in appetite signals? 

Dr Susan de Jersey 14:59   

I think it can come from a lot of things. Some women have a greater drive to eat, whether it can be physiological, whereas for other people, there are external triggers and social food environments, the social influences of people, and sometimes cultural practices wanting women to eat more to fuel the baby. So, I think it’s tricky to break down and generalise, depending on what that scenario is.  

Dr Sam Manger 15:26   

Well, sticking with a potentially another tricky topic. You know, weight gain is expected and normal during pregnancy. Are there guidelines around weight gain for pregnancy?  

Dr Susan de Jersey 15:35   

There are. So, there’s some widely used international recommendations which come out of the US Academy of Medicine, and they’re adopted throughout Australia in a number of sets of clinical guidelines. And essentially, these particular recommendations have come forward from large population based observational studies that look at optimal outcomes for both mother and baby, that looked at the frequency and severity of adverse events. And what those recommendations essentially do is break down the amount of weight recommended for a woman to gain based on a pre pregnancy body weight classification system, the body mass index. Body Mass Index classification is tricky on an individual level. So, there are obviously a need to individualise that, but essentially depending on pre pregnancy weight classification, the amount of weight gain recommended is different. 

Dr Sam Manger 16:33   

When should we be weighing women throughout pregnancy?  

Dr Susan de Jersey 16:37   

I think it depends on lots of things. Weight is, for many women, a sensitive topic, and does need, perhaps a nuanced and individualised approach. Weight in pregnancy can tell us lots of things about the health of a pregnancy, and it’s often referred to as a vital sign. So, we need a body weight measurement to accurately dose medications. There are weight limits on different equipment that we use during pregnancy, and so it can be important to have a body weight measurement.  

A body weight measurement can also tell us different things. So rapid fluid shifts, for example, might be an indication of pre-eclampsia. If someone is losing weight in pregnancy, it may signal some other event that needs further investigation. Having said all of those things, I think it’s important, as we care for women to understand any weight concerns and how women would like the process of having a body weight measurement taken and recorded that meets their individual needs.  

Whenever I would care for a woman during pregnancy, we would have a conversation saying why a weight measurement might be important and how somebody would like that to be done. We have the ability to blind weigh, which I will often do if there are any concerns about weight, but there are many, many women who are happy to weigh themselves and monitor their weight, to track their progress. So, I think it’s one of those perhaps tricky conversations to have in a really respectful, nonjudgmental way with women. Sometimes for women who’ve had weight concern or concerns about their relationship with food, pregnancy is a time that we can offer some support, and maybe the first time that they have had the opportunity to seek that support as well.  

Dr Sam Manger 18:23   

What are the name of the guidelines in this area? With weight gain?  

Dr Susan de Jersey 18:26   

They’re commonly referred to as the Institute of Medicine guidelines. And rather than rattle off a whole bunch of numbers depending on pre pregnancy body mass index, we might be able to pop in the link with the podcast, or something along those lines. They are different for twins and triplets as well. So, there’s, there’s a range of different recommendations around. 

Dr Sam Manger 18:47   

Stay with us, we’ll be right back to continue our conversation. 

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Dr Sam Manger 19:24   

And now back to the conversation!  

Kassia, there’s a number of common conditions experienced during pregnancy clearly relevant to your field, leg cramps, back pain, fatigue, constipation, morning sickness, that can affect how much one might feel like moving or eating well or engaging in life generally. What are some safe and effective self-care practices that healthcare professionals can recommend to pregnant women to manage some of these discomforts relevant to your field? 

Dr Kassia Beetham 19:51   

Becoming less sedentary is incredibly powerful, and direct comparisons between physical activity and sedentary behaviour are not clear, but it could potentially be as important as being physically active. So that can be an easy way for women to improve their health with less burden of feeling they need to go and do a structured exercise session for 30 minutes a day. So if women are feeling unmotivated to exercise, which I completely understand, we can break up exercise sessions into small bouts, so 10 minutes, for example, going for a walk outside in fresh air, can all help those conditions that you just mentioned, and could be a really great treatment or rehabilitation. So, if we can get women moving, then it can be a really powerful form of medicine. Yes, so breaking up sitting could be a tool for behaviour change that’s not as onerous as women feeling the burden of having to regularly participate in structured exercise.  

Dr Sam Manger 20:53   

So, it sounds like sedentary behaviour is an independent risk factor to some degrees, as well as the presence or absence of physical activity. Have you found with sort of the back pain certain, as we talk about sacroiliac joint or other aspects that you would commonly see women potentially suffer from throughout as pregnancy progresses. Are there specific programs or exercises or recommendations you might make, or resources you might recommend to women in that situation? 

Dr Kassia Beetham 21:20   

It’s important to note that in the physical activity guidelines, as we mentioned, they are similar to the adult guidelines, with the addition of pelvic floor exercises. So, the pelvic floor we can think of as the base of a canister. We also have in that canister our core muscles and our back muscles, our diaphragm, a whole lumbar, pelvic hip complex. So, they’re really important exercises that we need to target to reduce the severity of back pain and pelvic girdle pain as a whole. So, definitely working on pelvic floor muscle contractions is important but also seeing an exercise professional to help with exercises that are appropriate for that whole lumbar pelvic canister as well, can help reduce pain that’s really common in pregnancy. And it is individualised as well, so there are certain activities that may flare up pain. So, we would be looking at maybe reducing single leg movements, such as single leg lunges, cycling, things that split the pelvis could potentially be more aggravating, so we follow those general rules, but definitely individualisation is helpful. 

Dr Sam Manger 22:29   

And are Kegel exercises beneficial? They’re pelvic floor muscle exercises. So, would that be part of the constellation that you would do? 

Dr Kassia Beetham 22:35   

They are important, and they are in the guidelines to help reduce the severity, not necessarily the incidence, but the severity of incontinence in in pregnancy and postpartum, as I said, doing them in conjunction with other lumbar pelvic exercises, which aren’t as strongly touted in the guidelines, but potentially would be beneficial. It’s also important to state that you can over-contract your pelvic floor muscles without the appropriate relaxation, which can be just as harmful. So, if you aren’t able to see a women’s health physiotherapist or exercise physiologist, there are some apps available that can give you visual cues of contracting the pelvic floor that have the relaxation as well, which is just as important. Because if you have a tight pelvic floor, it can be tight and weak, and it can also cause pelvic pain.  

Dr Sam Manger 23:24   

So, these apps and devices, these like things like the PeriCoach, or are there certain things you’re talking about? 

Dr Kassia Beetham 23:29   

PeriCoach? I’m not familiar with that one. I like the NHS Squeezy because it gives a really nice visual cue of the contraction and the relaxation. 

Dr Sam Manger 23:37   

Now, one of the things that is fairly popular is yoga during pregnancy. Do you have any thoughts on that? Is that a reasonable recommendation, or is it something that has some caution attached to it as well? 

Dr Kassia Beetham 23:49   

No, I think yoga is great for stabilising muscles. I mean, you have to consider all of the normal precautions as the pregnancy progresses to avoid lying on your back, any aggravating movements, such as split leg stances should just be modified so that it’s not aggravating the pelvis. Obviously not hot yoga. But yeah, yoga is a really great exercise during pregnancy.  

Dr Sam Manger 24:13   

Great, and Susan, as we mentioned, these common conditions that can come up as morning sickness, constipation, very relevant to people’s food and dietary intake. Are there any food related strategies to manage some of these common symptoms, like nausea and early pregnancy or other aspects as pregnancy progresses? 

Dr Susan de Jersey 24:29   

Looking at morning sickness, for example, there are some strategies that can help. I mentioned earlier that some women experience the nausea that settles with eating, and we do see that small, regular meals or snacks, nourishing fluids can settle morning sickness, avoiding high fat, spicy foods is another strategy that can really reduce the impact of nausea and also reflux, which is not uncommon in pregnancy. Sometimes with morning sickness, people do prefer bland, low fibre foods, which can exacerbate constipation, and so often, there is a bit of a balance in trying to get in a good fibre to fluid ratio with keeping the nausea at bay. Sometimes those sort of higher fibre foods can not be well tolerated when someone has morning sickness. And so, there’s a number of different factors to balance out, and sometimes making sure medications are optimised is where we need to go, rather than the food-based strategies. 

Dr Sam Manger 25:33   

You’ll often see the sale of certain supplements, or ginger, for example, or certain vitamin B complexes and so on. Are they something you recommend and see benefit from? Ginger does seem to be effective in some nausea, vomiting, migraines, like disorders. But is that true in pregnancy as well?  

Dr Susan de Jersey 25:48   

I think it’s an individual approach. So, some women will swear by a particularly ginger, B complex vitamin, whereas others will get no relief from it whatsoever. So I think that’s one, when women coming in with that quite pervasive, ongoing nausea, we do sort of go back to what is working for you so that we can get them through that time and hope that it doesn’t last for a long period of time during the pregnancy.  

Dr Sam Manger 26:18   

Yes, absolutely. Now, moving along in the pregnancy. Now, can you tell us a bit more about best practice? And this is a big topic, but for women who’ve been diagnosed with gestational diabetes from their oral glucose tolerance test at 28 weeks, what’s the evidence-based care for this once they’ve been diagnosed? And does this happen universally across Queensland?  

Dr Susan de Jersey 26:38   

All women who have been diagnosed with gestational diabetes, GDM, often, as it’s referred to, should be referred to an Accredited Practicing Dietitian and a diabetes educator within a week of their diagnosis. The first line treatment for GDM, really, is through dietary modification and monitoring of self blood glucose levels to see how those dietary modifications are impacting, and that care should be ongoing throughout their pregnancy.  

Clinical guidelines recommend women reviewed at least three times by a dietitian. It’s similar to what I liken it to, is that if we ask someone to change something, whether it’s start a medication dose or start some dietary modifications, we need to see how that’s impacting a woman, and if we don’t provide that regular follow up, sometimes there can be unintended consequences, such as over restriction of dietary intake, which then might feed into other challenges, with increasing hunger, weight loss, impacting on the growth of the baby.  

Sadly, we know that across Queensland, most women won’t get access to that sort of care. Around a quarter won’t see get to see a dietitian, and most will only get the opportunity for a one-off group education session. There are some small pockets of women in public care that will get ongoing good dietetic care, and we know that that’s associated with good outcomes for women who might still have high blood glucose levels, even after changing their dietary intake and increasing their physical activity. They may need to go on to some medication to help reduce those blood glucose levels, and that can be distressing for some women, but really what we try and look at supporting them with is that this is the hormonal changes that are going on in the body, and reducing that judgment and blame that can sometimes go along with starting medication a sense of failure. And we certainly try and support women around that. 

Dr Sam Manger 28:31   

And there’s the sort of postpartum check as well isn’t there with GDM? One should follow up and make sure their sugars are normalising, and they’re high risk going forwards of diabetes so important to monitor?  

Dr Susan de Jersey 28:42   

Yes.  

Dr Sam Manger 28:42   

Now there was a large systematic review, meta-analysis in 2021 published by our Monash colleagues, that showed that structured diet and physical activity support programs, as you mentioned, Kassia, improved maternal and neonatal outcomes pretty widely and broadly and reduced the risks considerably, 25% – 50% in certain categories. We’ve got the good evidence now that these things really do make a substantial difference to both mum and bub and antenatal appointments offer that golden opportunity to discuss those lifestyle changes, nutrition, alcohol, smoking, moving, sleep, social connection and so on. So, coming to a point of initiating these conversations and supporting people from a behavioural activation point of view. And what have you found works when we’re working with expectant mothers and fathers in a nonjudgmental way, Kassia? 

Dr Kassia Beetham 29:28   

In terms of physical activity, I think it’s important to provide education and knowledge to help reduce some of that mum guilt, which we know is so prevalent in pregnant women. So, for example, if you’re previously very active, you can have it in your head, especially from social media, that I can maintain the same level of activity throughout my pregnancy, when, in reality, physiologically, your exercise is…is getting harder, so that goal post is moving. So, providing that education and knowledge to women. That if, for example, you’re doing 6,000 steps a day in trimester one, that may drop to 5,000 steps in trimester two, and that may drop to 3,000 in trimester three. It’s not that you’re getting lazier and you’re doing less, but physiologically, your body is working harder, and therefore you’re doing the same amount of work in less time. So, for me, I think education is really key in in promoting some of those behaviour changes and getting women and their partners on board with these healthy behaviours.  

Dr Sam Manger 30:30   

Any thoughts? 

Dr Susan de Jersey 30:31   

Yeah, I think one of the things that is worthwhile is understanding women’s stories and their journeys. We do, sometimes, see women wanting to come to pregnancy and have the perfect dietary intake, and sometimes that may be unachievable. And so, understanding where they’re at, what are their goal is and what are the key things that they feel like might be achievable in the short term. That brief intervention, understanding a couple of small changes, whether it’s including a little bit more fruit each day, might be diversifying the plants and vegetables that women are consuming and how they can overcome the barriers to getting there and doing that over repeated consults with women. So that brief intervention, checking back in and using really foundational behaviour change processes to support change over a long period of time in the pregnancy. 

Dr Sam Manger 31:26   

You mentioned some key components there around behavioural change, education, reducing stigma, and regular follow up, which is inbuilt in the antenatal process, luckily. So, there’s a real opportunity there that we are going to catch up with people every four weeks, two weeks depending, so we can definitely follow up people. Have you found the socialisation aspect for, you know, movement and food to be important, aka either the peer support component, or doing these movement with other women, just so that it can be one can have a laugh about it, but also normalise it in the sense that this is what we’re going through together, so to speak.  

Dr Kassia Beetham 31:59   

Definitely having that support group is really beneficial for making changes and just having everyone aware of what the guidelines are. So, the most recent Physical Activity Guidelines included vigorous intensity exercise for the first time, and that can take some time to get people on board. So, there may be older generations who still feel quite alarmed at seeing a lady with a big bump going for a run. So just education and getting your network and the people around you on board with what’s appropriate and safe and effective in exercise can be really helpful. There’s also a lot more social media support out there, which can be a good and a bad thing. So, there’s a lot of non-health professional advice and apps out there, which may be helpful depending on where you are in your journey, but getting some health professional social media with some solid advice and creating a really education evidence-based network of people can be really supportive for your pregnancy journey.  

Dr Sam Manger 33:00   

So, there’s a sort of offline component, aka the face-to-face human component, but there’s also online connection. We can get that social connection too through various sources. Do you find the same with the food aspect? 

Dr Susan de Jersey 33:10   

Yeah, I think when we look at the evidence around particularly behaviour change in the context of nutrition, the supportive home environment and the broader social ecological system is really important to supporting women with changes to dietary behaviour. Blended interventions that incorporate support from a qualified health professional is an important component to that, along with some digital technology.  

But what we also find is that for women, often during pregnancy, there can be a high appointment burden, and they’re juggling multiple things, whether that’s childcare responsibilities, working, and so we need to find some solutions to be able to support women in a variety of ways, to support that broader behaviour change, and not necessarily have the responsibility fall just to the woman. It’s that broader society context as well as the family unit, that we need to be bringing along the journey.  

Dr Sam Manger 34:08   

So on that side, and I agree, do you find it useful to then involve the partner and other relevant family members or caregivers into the consults, to have these wider conversations about, how do we change the micro culture as it were, to best support the health of mum and bub and dad? 

Dr Susan de Jersey 34:26   

In an ideal world, I would love to say that happens, and at every opportunity that we get, we would invite families and other extended family to be part of that conversation. I think in reality now is that if there’s multiple people working that it might just be one woman coming to the consult, and so it’s more around how they can enlist that support, and what some of the strategies might be to do that. And I think that’s where the narrative at a broad society level is that this is a shared responsibility. And you know, in pregnancy, we know that the family unit has such a big impact on that, and I’m a big advocate for it not to be just the woman’s responsibility. 

Dr Sam Manger 35:10   

Makes sense. And I mean, it does help, because by having these conversations, we’re identifying the gaps, you know, you mentioned some of the gaps around access to dietitians for women with gestational diabetes, especially. I imagine rural and remote parts of Queensland and Far North Queensland and those aspects. So, it’s very important for us all to be aware of these gaps and how we can come up with, usually, innovative solutions to those. And likewise, changing the concept that we have to focus on the mother and the mothers responsible for all of these changes. Well, of course there’s some responsibility, but as is there to the greater family unit as well. 

Dr Susan de Jersey 35:41   

I think it’s worth noting that particularly the food environment now is so incredibly complex that it’s difficult for even well-educated people to navigate. There’s a lot of social media influence on what people should and shouldn’t be doing, and it’s not necessarily evidence based, and being able to sort of come together to support that narrative, and how do we unpack some of this and have that multi system level approaches to changing the broader food environment, appreciating the time it takes and understanding the complexity to help people navigate that and not necessarily see it as this individual responsibility that I’ve got to try and filter through all of these mixed messages that might come across as an individual. 

Dr Kassia Beetham 36:26   

In terms of exercise, I think it’s really important to communicate strongly with the partner early on how important it is for the baby and also for the mum as well. And if that physical activity time isn’t already carved into a woman’s day that the partner can help facilitate that, and having that conversation early, before you know you’re right in the trenches, can be helpful. It might be important for the mum to be able to go for a walk on their own without taking the pram with them. So having that expectation of how the partner can support the role in the mum being physically active as well is important to do early on.  

Dr Sam Manger 37:03   

Absolutely, that does open the question around working with people from diverse, different cultural backgrounds, because there can be quite different perceptions of this. You know, we talked about the sort of traditionally in a way, a Western, individualistic attitude, whereas we’re now talking about zooming out, looking at the collective whole here, both the family unit and the community as well, and so that does sort of naturally lead us to how we can address and bring in, indeed, cultural beliefs and practices that are very healthy for antenatal practices. But how do we ensure our advice is respectful, sensitive, but also inclusive, and brings in these ideas? 

Dr Susan de Jersey 37:40   

When we bring that Western philosophy in, it does have the potential to ostracise different cultural groups, and we do sometimes see that through nonattendance at inter-natal care appointments. And so certainly for me, as I practice, it’s really having open conversations in a really non-judgmental way around what are the cultural beliefs and practices that are really important to you to continue with and looking at how we can adapt different aspects of care to suit those. I said earlier that sometimes it is challenging to get partners to come to appointments. What we can sometimes see in different cultural groups is that mothers, mother in laws, will come to appointments and support women, and that offers this really beautiful opportunity to start to integrate some of those, those practices, and understand what aspects might be negotiable to support the particular health of the woman and the growing baby versus other things. So, you know, when I’ve been caring for women with gestational diabetes, for example, and it’s Ramadan, how can we look at adapting some of those practices, but really understand the impact on your health and where there might be a level of compromise? And similarly, there are some particular cuisines that do make it really challenging to optimise diabetes management, for example, around very high carbohydrate, low protein, dietary cuisines. And we do a lot of negotiation in that to say, how can we adapt to meet your needs and achieve the cultural practices that are important to you? And I think the family becomes a really important component of that.  

Dr Sam Manger 39:21   

Don’t go anywhere, our conversation continues after these messages. 

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Dr Sam Manger 40:01   

And now back to the conversation.  

Kassia, I’m curious around this question of working with people from diverse cultural backgrounds, because, you know, food is an obvious example where there is incredible diversity and represents different cultures and movement. There seems to be a common core set to all of us in some ways. So, do you find you have to change your assessment and management? Or there’s certain resources you often use for, say, First Nation People or culturally diverse people, you find that is pretty common across all different cultures and so, movement rules? 

Dr Kassia Beetham 40:27   

Yeah, it’s very individualised. And that’s the benefit of having an exercise physiologist, is being able to apply all of the different factors in front of you to get the best outcome for the person. Part of it is cultural, but a bigger part of it is enjoyment and motivation and what they’re actually going to do. So, we need to do a really good, subjective assessment and find out exactly what’s going on in their life, and we’re not going to give them three sets of ten repetitions of a TheraBand exercise if they’re not going to do it. So, asking the right questions and being respectful of their traditions and what’s going on in their life. So, we want to be able to fit the exercise into their daily routine, something that they can continue for the rest of their life.  

Dr Sam Manger 40:29   

So, this certainly opens up that further question we talked before about, how do we initiate healthy behaviours in pregnancy? And then there’s a question of, how do we support people to maintain those because there’s often a, usually studies would point to about a “three week mark behavioural decay”, where most humans are happy to try things for three weeks, and then we generally get not very good at it, and then we get a bit bored of it or something. So how do you both and Kassia, please start. How do you support women to maintain that during pregnancy, and dare I say, you know, thereafter? 

Dr Kassia Beetham 41:40   

I think being flexible is the key here. I mean, personally, I don’t like doing a particular exercise for, like, more than a year, so I think it’s important to adapt over the lifespan. We’re going to go through so many different changes. You know, you have children, you’ve got to work around time of day, and that all happens in pregnancy as well, and albeit in just a shorter period of time. So, if you’re feeling like you’re not being as active as you would like, getting that support from an exercise physiologist can help you decide or choose exercises that does complement your life and it’s something that you enjoy. So, I think being flexible, and if it’s yoga, if it’s Pilates, if it’s going for a run, we can make it work. Just speak to someone who knows how to adapt it appropriately and will, should, in most cases, be able to fit it into your lifestyle, as long as it’s not, you know, skydiving or scuba diving or horse riding. 

Dr Sam Manger 42:35   

Yeah, trampoline, bungee jumping.  

Dr Kassia Beetham 42:37   

Yep.  

Dr Sam Manger 42:38   

Susan, have you found that anything is a consistent principle of helping people maintain those things that are so good for them? 

Dr Susan de Jersey 42:45   

I think one of the things I find useful is that regular contact with a health professional or somebody who’s in your corner to help coach you through those things, particularly, what are the barriers that have now got in the way? Which are the bits you’re not enjoying, which are the things that you’re actually finding quite easy and tapping into, where the adaptations can come in to help sustain those behaviours. And often it is whether there’s been a triggering event that has made continuing with what you started tricky, or identifying where the next step is. One of the things we found in some of our more recent research is that when women feel like the framing of messages is positive, that they’re adding things in, they’re enjoying what they’re eating and the changes they’re making, it’s easier to sustain than if they feel like they’re depriving themselves of something, or they’re having to cut things out, and that things are really hard, and so looking at how we can frame any changes that are needed in that really positive way that are easy to do. 

Dr Sam Manger 43:52   

Yeah, fantastic. And you mentioned before Kassia around the idea of play after a pleasure, actually enjoying what you’re doing and having variety and going with the flow. You don’t have to do running for six or 12 months, or whatever it is. You can do running this week, swimming the next week. Enjoy your body. Explore your body. Enjoy it. The best exercise you do is the one you do, and the best time to do it is the time you do it.  

So now there’s a big question here around resources, and especially we’ve talked about the rural, remote aspect, so that’s incredibly relevant, and utilising technology, or leveraging technology like apps, and we mentioned a couple like, and telehealth, to support physical activity and movement and make it more accessible and engaging. So, do you, both of you, have go-to’s for, say, resources along this to help with people, Susan? 

Dr Susan de Jersey 44:37   

I think the evidence in the app space particularly, is a bit like you mentioned; people use them for a short period of time, and then they’re not sustained. So, I am not necessarily one to recommend an app, per se. What we do find is that those push text messages can be a bit more effective. In the work that we do, we will schedule telehealth appointments. One of our programs we do all remote now, so telephone, to be able to offer women the opportunity to do it from wherever, and that’s what we have found more successful than necessarily jumping onto an app. And maybe that’s just because the best one hasn’t been found yet, and lots of people are still sort of on that journey, I think, to find what works. So that’s sort of where we’re at.  

Dr Sam Manger 45:25   

And what are your go to resources then, for either professionals or yourself? Is there a certain association you use for this, or is it sort of the guidelines for pregnant women? 

Dr Susan de Jersey 45:37   

Certainly, for health professionals, I would stick with the guidelines in Queensland, we’ve got an awesome set of clinical guidelines which are much more focused, I guess, on management of particular conditions. The ‘Eat for Health’ website is pretty good. Health and Wellbeing Queensland, I think, have got, particularly around recipes, and keeping exercising are worthwhile thinking about. And then we’ve got nutrition education materials online, which health professionals can use. Dietitians Australia is another great resource.  

Dr Sam Manger 46:09   

Are there any go to either technologies or apps or resources you would use, either for the public as a great resource, or for pregnant women or for the health profession, Kassia?  

Dr Kassia Beetham 46:19   

We do have the physical activity guidelines, as we’ve discussed before. We have a professional version available from Exercise and Sport Science Australia, and also the public version, which is available on the government health website. In terms of apps, I have mentioned the NHS Squeezy app for pelvic floor exercises, I find that quite helpful to maintain a program with doing the pelvic floor exercises, because they can be quite boring. Other than that, again, it comes back to what you enjoy. If you’re not going to use an app, then probably don’t waste your $12 on starting one. The biggest barrier to exercise is fear of harming the baby. So, for a lot of women, just having those tele-health appointments with an Exercise Physiologist who specialises in women’s health can provide that reassurance and that little nuanced advice for different movements to encourage women to exercise during their pregnancy.  

Dr Sam Manger 47:14   

I mean, it’s great that we’ve covered some of the sort of red flags or things that women should be aware of around movement, but it seems like from the change in the guidelines is the first time they’ve added vigorous intensity exercise. So, it would indicate that it is very healthy for the baby, as a general rule, to move but obviously there are always caveats and nuances to those sorts of statements.  

Dr Kassia Beetham 47:31   

So, the vigorous intensity is based on research that has been prescribed up to 90% of maximum heart rate. So, we do recommend not going above 90% maximum heart rate at this stage, not to say it is dangerous, but we just don’t have the research yet to show that, and we’re still currently looking at research into volume of exercise as well. So, intensity that’s vigorous, it’s short, sharp, seems to be completely fine for the baby. What we need to look at now is, if there is an upper limit of how much of this we can do, and what are the impacts. So, it’s still a work in progress, but we are making steps forward. 

Dr Sam Manger 48:10   

It sounds like it. And just to nerd it up a little bit, maximum heart rate, the formula for that is?  

Dr Kassia Beetham 48:15   

We just do 220 minus age. 

Dr Sam Manger 48:18   

Yep, so 90% of that. So pretty decent. Most women are going to be 30, give or take during their pregnancies.  

Dr Kassia Beetham 48:23   

So, the past limit of only going to 140 beats per minute is out the door. And that was 20 years ago, but I still hear it floating around so.   

Dr Sam Manger 48:32   

So, we’re looking at sort of 170 ish?  

Dr Kassia Beetham 48:34   

Yes. 

Dr Sam Manger 48:35   

Yeah. Very good. All that’s very reassuring. Finally, just to wrap this excellent conversation up. I’m curious, because we both mentioned social media a little bit in the sense of I suspect all health professionals are frequently presented with myths and facts and truths that they’ve heard from their patients who’ve heard from social media, and that sometimes is interesting and fun to explore and sometimes slightly triggering. So are there one or two top things you wish every woman knew as they entered pregnancy, or the father, we can enter the dads into this as well. But women, in particular. Susan? 

Dr Susan de Jersey 49:08   

One of the things to me is that there is no right, one right way to experience a pregnancy, and if I think about that from a nutrition point of view, women’s taste preferences can change profoundly during pregnancy, and so there can be a level of guilt, I guess, wrapped up in that. And so, making sure women don’t feel like they need to cut out whole food groups, dropping some of the food rules to understand that you can enjoy a range of nutritious foods. But it doesn’t need to be perfect, and so if women do have concerns, that pregnancy can be a really great time to start to unpack some of those food rules, or getting some support around navigating the complexity of all of the information that they might be trying to take in around nutrients and foods.  

Dr Sam Manger 50:01   

Excellent. Thank you. Kassia?  

Dr Kassia Beetham 50:03   

So, after the baby is born, I’ve noticed there is a tendency for women to want to jump straight back into what they were doing before they got pregnant, whether that’s being sedentary or running marathons. So what I like to tell them instead is to try and slowly increase movement into your daily routine, because eventually your little play bosses, they’re going to want you to jump on the trampoline and kick soccer balls with them, and you don’t want to miss out on those moments because you’re injured or inactive.  

Dr Sam Manger 50:28   

Yeah, great. I mean that play aspect’s so important and they will work you out. There’s no doubt about it. So, thank you both for joining us and look forward to seeing you again next time. 

Dr Kassia Beetham 50:37   

Thanks for having us.  

Dr Susan de Jersey 50:38 

Thanks for having us. 

Dr Sam Manger 50:40   

Today, we’ve been talking to Dr Susan de Jersey and Dr Kassia Beetham about antenatal women’s health. For more information on today’s topics, visit the Health and Wellbeing Queensland website at www.hw.qld.gov.au If you’ve liked today’s conversations, be sure to subscribe for future episode updates. We’ll see you next time on the Clinician’s Guide to the First 2000 days.