title: UTILISATION OF REMOTE MONITORING TO EXAMINE PHYSICAL ACTIVITY, METABOLIC HEALTH, AND WELLBEING ACROSS THE PERINATAL PERIOD
Creators: name: France, M
Publisher: name: Liverpool John Moores University
Year: 2024

description: It is well established that physical activity (PA) is beneficial for overall health and that physical inactivity increases the risk of development of type 2 diabetes mellitus (T2DM) and other lifestyle influenced, non-communicable long-term conditions. Importantly, glucose variability provides important prognostic insight for individual metabolic health prior to the onset of T2DM and provides valuable information pertaining to glucose control as a research methodology. Healthy metabolic processes adapt during pregnancy to adequately provide for the needs of the developing foetus. However, metabolic dysfunction during pregnancy can lead to gestational diabetes mellitus (GDM). Even though PA has been found to decrease the risk of GDM, many pregnant women fail to meet recommended PA guidelines. Sport England report that between mid-November 2020 and 2021, 61.4% of adult achieved the recommended PA guidelines, whilst 27.2% of adults were defined as physically inactive (Sport England, 2021), which may have long term implications for the metabolic health of the population. Additionally, remote research methodologies that prevent face-to-face contact and virus transmission during the coronavirus 2019 (COVID-19) pandemic, whilst also increasing the reach and sample of participants are warranted. Continuous, device-derived measurement techniques, such as accelerometry and continuous glucose monitoring (CGM) allow the quantification of the duration and magnitude of daily PA and glucose control, respectively. Yet, the feasibility and acceptability of remote data collection for clinical value via these methods remains unknown. The overarching aim of the body of work described in this thesis was to investigate the acceptability and feasibility of remote data collection to explore PA and glucose control across the perinatal period. In addition, due to the timing of this data collection and the World events that were impacting habitual lifestyle and healthcare at the time, thematic analysis of semi-structured interviews sought to identify pregnant women’s perceived barriers to antenatal exercise and the impact of the COVID-19 pandemic on the pregnancy experience. Chapter 4 explored the feasibility and acceptability of remote data collection, in addition to the effectiveness of two home-based exercise interventions. Anthropometric data, blood samples, CGM, and PA data were collected remotely prior to and following a home-based exercise intervention incorporating i) mobile health (mHealth) technology and exercise counselling, or ii) online resources only. Semi-structured interviews to explore participant experiences were conducted pre- and post-intervention. Data provided novel evidence that remote testing is a feasible approach to obtain data, however further refinements were required to increase data availability. These adaptations were then implemented in Chapter 5. Moreover, low levels of intervention drop-out (16%), promising preliminary health outcome data, such as a greater increase in moderate-to-vigorous PA (MVPA) completed in 10-minute bouts (MVPA+10) in the mHealth group (58 min/wk; CI= -0.06, 0.98, d= 0.47) compared to the online resources group (14 min/wk, CI= -0.32, 0.54, d= 0.12) and positive participant perceptions reinforce the effectiveness of home-based exercise interventions, that incorporate individualised support and mHealth technology. Chapter 5 utilised those remote testing techniques piloted in Chapter 4 to determine the relationship between PA and glucose control across the perinatal period, disaggregated by trimester including postpartum, using objective continuous assessment methods. Forty-nine pregnant women underwent remote assessment of CGM and PA at trimesters 2 (T2) and 3 (T3), and within 6 weeks postpartum (T4). Glucose variability and PA patterns, as well as the relationship between glucose control and PA across the perinatal period were assessed. Findings firstly, demonstrated slightly higher levels of glucose variability during pregnancy in comparison to postpartum, whereby 24-hour variability decreased, albeit non-significant, between postpartum and T2 (mean difference: -2.15%; CI= -4.52, 0.23; P=0.08) and decreased from postpartum and T3 (mean difference: -2.45%; CI= -4.69, -0.21; P=0.03). Secondly, there was an increase in total (mean difference: 53:45 min; CI= 0.72, 106.79; P=0.11) and light (mean difference: 48:13 min; CI= 15.77, 80.70; P=0.004) PA levels from T2 to T4, with no change in moderate-to-vigorous PA (MVPA) (P&gt;0.05). Finally, there was no relationship between 24-hour or daytime glucose control and PA at any timepoint. Notably, participants recorded low levels of PA at all timepoints, which may have hindered power to detect any relationship. Importantly, novel data demonstrating a decrease in glucose variability at postpartum in comparison to during pregnancy should be noted and may be linked to physiological and behavioural changes (e.g. changes in insulin response during pregnancy or breastfeeding) that occur across the perinatal period. Chapter 6 collected rich, in-depth qualitative data to contextualise findings in Chapter 5 and reflect women’s perceived barriers to antenatal exercise during COVID-19 (question 1) and their perceptions of the pregnancy experience during COVID-19 (question 2). Questionnaires reporting anxiety, depression and PA levels were completed by all participants (n=14). Semi-structured interviews were conducted between November 2020 and May 2021. Interviews were analysed using thematic analysis for each research question, individually, to provide two sources of information. Question 1 revealed four main themes: ‘Perceptions of being an active person shaping activity levels in pregnancy’, ‘How do I know what is right? Uncertainty, seeking validation and feeling informed’, ‘Motivators to antenatal exercise’ and ‘A process of adaptations and adjustment’. Question 2 also revealed four main themes: ‘Navigating changes to healthcare delivery and antenatal care’, ‘Adapting to lifestyle changes’, ‘Decision making in the context of COVID-19’, and ‘Seeking support during COVID-19’. The findings of the study highlighted the importance of direct psychosocial support and clear, trustworthy information for pregnant women. Findings also support the fundamental need for better education amongst healthcare professionals regarding antenatal exercise. Collectively, the data contained within this thesis support the feasibility of remote data collection and remote exercise interventions that include mHealth technology. This highlights the potential use of such tools in healthcare to provide clinical exercise physiology support in an economically viable manner. Data revealed increased glucose variability during T2 and T3, accompanied by low levels of PA during healthy pregnancy. Nonetheless, no relationships between PA and glucose variability across the perinatal period were observed, suggesting that physiological and behavioural changes occurring across gestation may impact glucose variability. Finally, qualitative data revealed themes of uncertainty around exercise and PA during pregnancy which highlights the importance of psychosocial support for pregnant females and education for healthcare professionals (HCPs) regarding ante- and post-natal exercise. Although these data were collected during the COVID-19 pandemic, the application of findings transcends this timeframe.