European Journal of Clinical Nutrition (2014) 68, 760–766 © 2014 Macmillan Publishers Limited All rights reserved 0954-3007/14 www.nature.com/ejcn

PUBLIC HEALTH NUTRITION HIGHLIGHTS REVIEW

Technology-supported dietary and lifestyle interventions in healthy pregnant women: a systematic review OA O’Brien1, M McCarthy2, ER Gibney3 and FM McAuliffe1 Overweight and obesity are associated with increased risk of adverse maternal and fetal outcomes. However, the actuality of delivering effective lifestyle interventions in clinical practice is hampered by a high demand for resources. The use of technology to assist lifestyle interventions needs to be explored as a valid method of reducing strain on resources, and enhancing the effectiveness and population reach of interventions. The aim was to systematically review the literature on the use of technologysupported lifestyle interventions for healthy pregnant women and their impact on maternal outcomes. Online databases and registries were searched in March 2013. Primary outcomes of selected English language studies were fasting maternal glucose, incidence of gestational diabetes mellitus (GDM) and maternal gestational weight gain. Secondary outcomes were intervention uptake and acceptance, and dietary or physical activity modification. Studies whose subjects were diagnosed with GDM prior to intervention were excluded. The minimal number of eligible studies and varying outcomes precluded formal meta-analysis of the data. Initially, 203 articles were identified and screened. Seven articles, including five randomised controlled trials, met inclusion criteria for the current review. Results demonstrate several potential benefits associated with technology-supported interventions in pregnancy, despite minimal search results. Although communication technology holds potential as a safe therapeutic tool for the support of lifestyle interventions in pregnancy, there is a paucity of data on its effectiveness. Further RCTs examining the effectiveness of communication technology are required, particularly among those most likely to benefit from lifestyle interventions, such as overweight and obese pregnant women. European Journal of Clinical Nutrition (2014) 68, 760–766; doi:10.1038/ejcn.2014.59; published online 30 April 2014

INTRODUCTION The importance of maintaining a healthy lifestyle and achieving healthy gestational weight gain (GWG) during pregnancy is well documented.1–5 However, approximately half of the pregnant women in Ireland, the United Kingdom and the United States of America are classified as overweight or obese,6–8 enter pregnancy approximately 10 kg heavier than they did 20 years ago9 and tend to gain more weight during pregnancy.10 Maternal obesity is associated with a significantly heightened risk of maternal and fetal morbidity and mortality, as well as intergenerational predisposition to obesity and other chronic diseases.11–23 The antenatal period represents a crucial opportunity to break this cycle of adverse health outcomes because pregnant women have regular contact with health-care professionals (HCPs) and are often motivated to make health behavioural changes that may optimise the outcome of their pregnancy.24–26 There are currently three ongoing trials that are sufficiently powered to demonstrate convincingly whether lifestyle intervention is likely to improve pregnancy outcome or not: LIMIT27 (Australia), UPBEAT28 (Europe) and LIFE-Moms29 (USA). It is widely accepted that effectively communicated, standardised, patient-centred education is essential for effective lifestyle interventions.30–33 However, delivery of such education requires time investment from both patient and HCP, and cost of employing an appropriately trained HCP to deliver the education. Furthermore, there is a limit to the number of women who can attend an education class at one given time, as well as a significant likelihood that those who need healthy

lifestyle education the most, such as women of lower socioeconomic status, may decline to participate in education sessions.34,35 Therefore, the delivery of healthy lifestyle education for pregnant women needs to make effective use of available resources while maximising population reach. Although technologysupported interventions offer a plausible solution to provide adjunct support to traditional face-to-face contact methods, there is currently a paucity in the literature surrounding the use of technology-supported lifestyle interventions in healthy pregnant women, as evidenced by the absence of any published literature reviews in the area. For the purpose of the current review, technology-supported lifestyle interventions are defined as dietary, exercise or health behavioural interventions that incorporate significant contributions from telephone, video, internet or mobile application (app) technologies. The term ‘healthy’ pregnant woman refers to women who have not been diagnosed with gestational diabetes mellitus (GDM) or any other common medical condition associated with pregnancy, and encapsulates all BMI categories. Thus, the aim of the current review is to systematically review the literature examining technology-supported lifestyle interventions among healthy pregnant women, and to determine the potential impact that such interventions could have on modern antenatal care. MATERIALS AND METHODS The current systematic review was conducted according to the recommendations of the PRISMA statement.36 The PubMed, MEDLINE, CINAHL,

1 UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland; 2Food Business and Development, University College Cork, Cork, Ireland and 3Institute of Food and Health, UCD Centre for Molecular Innovation, Science Centre South University College Dublin (UCD), Dublin, Ireland. Correspondence: Professor FM McAuliffe, UCD Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Dublin, Ireland. E-mail: fi[email protected] Received 14 November 2013; revised 21 February 2014; accepted 2 March 2014; published online 30 April 2014

Technology lifestyle interventions in pregnancy OA O’Brien et al

761 EMBASE and Cochrane databases were searched in March 2013 for eligible human-based studies. Only English language articles were included. Combinations of the search terms ‘technology’, ‘smart phone’, ‘app’, ‘mobile phone’, ‘telephone’, ‘email’, ‘video’, ‘internet’, ‘website’, ‘pregnancy’, ‘nutrition’, ‘lifestyle’ and ‘intervention’ were used to identify eligible studies. Owing to the lack of published randomised controlled trials (RCTs) on the topic, cross-sectional observational studies, feasibility studies and ongoing trials were included. Online trial registries (www. controlled-trials.com and www.clinicaltrials.gov) and related journals (American Journal of Obstetrics and Gynaecology; British Journal of Obstetrics and Gynaecology) were also searched for eligible studies. Abstracts of the publications identified by the primary search were reviewed and the references of included manuscripts were also searched for additional, potentially important publications. Multiple abstracts from the same authors or data set were identified to avoid duplication. The primary outcomes were fasting maternal glucose during pregnancy, incidence of GDM diagnosis and maternal GWG. Secondary outcomes included were intervention uptake and acceptance, and dietary or physical activity modification. Studies whose subjects were diagnosed with GDM prior to intervention were excluded. The minimal number of eligible studies and varying outcomes precluded formal meta-analysis of these data.

RESULTS Study characteristics The review process is outlined in Figure 1. Seven trials met the inclusion criteria—five RCTs37–41 and two cross-sectional observational studies42,43 involving technology-supported lifestyle interventions in pregnancy were identified. Four of the five RCTs included are currently ongoing. The methodologies and outcome measures of the selected papers are summarised in Table 1 and results are presented in Table 2. All seven trials were performed in developed countries: four in the United States, two in the Netherlands and one in Australia. The pooled RCTs included a total of 4500 participants and the pooled non-RCTs included 15 328 participants. For all included RCTs, the control group received standard care. In the cross-sectional observational studies, one study42 did not use a control, whereas the other study43 used the national population of pregnant Dutch women as a control. The outcomes investigated in the trials were GWG, GDM, route of delivery, birthweight, gestational age at birth, selfreported dietary and physical activity behaviours, and intervention reach, attrition and engagement. Effects of intervention on outcomes Two of the five RCTs recorded incidence of GDM; four measured GWG; one recorded route of delivery; three measured birthweight; one measured gestational age at birth; all five measured

Figure 1.

Search strategy.36

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self-reported dietary or physical activity behaviours. Both crosssectional observational studies reported programme reach, attrition and engagement. Intervention characteristics There are various types of technology-supported interventions available. For the purpose of the current review, they were categorised as basic telephone interventions—telephone calls and text or multimedia messaging; video interventions; internet interventions;44 and application (app) interventions on smart phones or tablets. An app is defined as a self-contained program or piece of software designed to fulfil a particular purpose (Oxford English Dictionary; http://oxforddictionaries.com/definition/english/app?q=app) that can be downloaded by a user to a mobile device. One of the five RCTs was based on telephone or text message interventions,37 one on a video-led intervention,38 one on an internet (website) intervention39 and two on smart phone app interventions.40,41 Six37–40,42,43 of the studies included both dietary and physical activity guidance; and one41 contained physical activity guidance only. Both crosssectional observational studies analysed the same internet-based intervention. Consistency of findings Lack of completed RCTs37,39–41 and heterogeneity of outcome measures used by the studies included in the current review prevented identification of consistent outcomes across included studies. Few studies presented data on important clinical pregnancy outcome measures such as the incidence of GDM or route of delivery, although most studies included GWG. The findings of the current systematic review, which are categorised by mode of technology (telephone, video, internet, app), are discussed in further detail below. Summary of the findings Telephone-supported lifestyle interventions in pregnancy. Only one RCT examining the use of a telephone-supported lifestyle intervention in pregnancy was identified.37 The trial is currently ongoing and in the recruitment phase. Hence, at this time there is insufficient evidence as to the effectiveness of telephonesupported lifestyle interventions in pregnancy. Video-supported lifestyle interventions in pregnancy. One RCT included in the current systematic review evaluated the effect of a video-based lifestyle intervention in pregnancy.38 The ‘Video Doctor’ intervention did not result in statistically significant differences in GWG, the primary outcome, and did not evaluate other clinical outcomes such as maternal glycaemia. However, it resulted in statistically significant increases in secondary outcomes—self-reported physical activity (P o 0.05), healthy eating behaviours (Table 2), nutritional knowledge (P = 0.009) and patient–clinician discussions about these topics (P o 0.0005). The study was limited by small sample size (n = 321) and timing of intervention (19 weeks gestation). Therefore, although the ‘Video Doctor’ intervention appeared to significantly improve physical activity level, healthy eating behaviours, nutrition knowledge and patient–clinician discussions, insufficient powering and several limiting factors may have prevented the reflection of such health behaviour improvements in clinical outcomes such as GWG. Internet-supported lifestyle interventions in pregnancy. Two internet-supported lifestyle interventions in pregnancy were identified in the current review. The Dutch ‘Hello World’ national health-promotion programme for pregnant women was evaluated by two studies. Van Zutphen et al.42 found that programme uptake was low (9% of n = 1382), and those who enrolled were mostly highly educated and already led a healthy lifestyle. Women European Journal of Clinical Nutrition (2014) 760 – 766

European Journal of Clinical Nutrition (2014) 760 – 766

Physical activity monitor measured steps

Proportion of pregnant women who gain more weight during pregnancy than is recommended by the Institute of Medicine

Associations between usage and user characteristics

Programme reach, attrition and engagement for an online healthy lifestyle programme for pregnant women The representativeness of participants in relation to the Dutch population

Relationship among GWG, maternal physical activity and diet, and incidence of GDM; birthweight; fetal adiposity; maternal weight retention postpartum; infant dietary habits 7-Day physical activity recall

Differences in recruitment, programme use, programme appreciation among women

Caloric intake and physical activity levels during pregnancy and postpartum

Nutritional knowledge and GWG

GWG and postpartum weight retention at 18 months

Self-reported dietary and physical activity behaviours

Rates of GWG; incidence of macrosomia; maternal glycaemia; self-efficacy and psychological wellbeing

Secondary outcome(s)

Single-blinded (subject) RCT

RCT

Cross-sectional observational study

Cross-sectional observational study

Double-blinded RCT

RCT

RCT

Study design

Est. 50

Est. 306

13 946

1382

Est. 3453

321

Est. 370

n

English-speaking pregnant women with pre-pregnancy BMI >23 kg/m2 Mean BMI, mean age and parity not yet established

English-speaking overweight or obese pregnant women aged 18–40 years Mean BMI, age and parity not yet established

Mainly high-income healthy pregnant womena Mean BMI not stated Mean age: 29 years, 63% primiparous

Mainly high-income, primiparous, healthy pregnant women Mean BMI not stated Mean age: 31a

English-speaking pregnant women Mean BMI, age and parity not yet established.

Low-income, Englishspeaking healthy pregnant women Mean BMI: 27.0 kg/m2 Mean age: 26 years 47–54% multiparous

Overweight or obese pregnant women Mean BMI, mean age and parity not yet established

Population characteristics

Mobile phone-based physical activity programme Intervention: participants receive an activity monitor and a mobile phone-based physical activity intervention using a smart phone app at o 20 weeks gestation Control: physical activity monitor only

Participants randomly assigned to 1 of 3 programmes to help manage their weight during pregnancy Physician-directed group (control) SmartMoms-Clinic group (intervention involving group education sessions); SmartMoms-Phone group (intervention involving individual education sessions with a smart phone app support)

As above. Data of pregnant women who enrolled during 1st year of ‘Hello World’ Control: all pregnant women in The Netherlands

Group 1: behavioural intervention through website during pregnancy only Group 2: behavioural intervention through website during pregnancy until 18 months postpartum Group 3: control—usual care ‘Hello World’ programme (emails containing quizzes with pregnancy-related questions tailored to the number of weeks of pregnancy) sent out once every 4 weeks, up to a maximum of nine emails.

Brief messages about diet, exercise and weight gain were delivered by an actor-portrayed ‘Video Doctor’ at randomisation and ~ 6 weeks later Control: usual care

Participants receive a healthy lifestyle programme, via brief phone contact alternated with a text message/email. It involves goal setting, behaviour change re-enforcement with weekly weighing and charting, and the provision of health information Control: usual care

Intervention/control

Ongoing 12 weeks

Ongoing, Est. 6 months

4 Months

4 Months

2 Years

4 Months

Ongoing Est. completion date not specified (not yet recruiting)

Time span

San Francisco, CA, USA

Antenatal clinics and primary care settings, Pennington, LA, USA

Nationally across The Netherlands

Midwifery practices in Amsterdam, The Netherlands

4 Hospitals in Rochester, NY, USA

Antenatal clinics in San Francisco, CA, USA

Primary care setting in Victoria, Australia

Setting

Abbreviations: app, application; BMI, body mass index in kg/m2; Est., estimated; GDM, gestational diabetes mellitus; GWG, gestational weight gain; N/A, not applicable; RCT, randomised controlled trial. a User characteristics were self-reported.

NCT01461707,41 ongoing

Smart phone app NCT01610752,40 ongoing

Bot et al.43

Van Zutphen et al.42

Internet NCT01331564,39 ongoing

Video Jackson et al.38

Telephone and text messaging Incidence of GDM Nagle et al.,37 ongoing

Primary outcome

Summary of outcome measures and methodology of studies included in the systematic review

Author and reference

Table 1.

Technology lifestyle interventions in pregnancy OA O’Brien et al

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Technology lifestyle interventions in pregnancy OA O’Brien et al

763 of lower educational achievement were significantly more likely to drop out (P = 0.02). The authors concluded that disadvantaged women who need the intervention most were the least easily reached. These outcomes were reaffirmed by Bot et al.43 who found that women of lower educational achievement were significantly more likely to drop out than their higher-educated counterparts, even though they had significantly more appreciation for the programme. Results of both studies reported high dropout rates. The effect of this internet-supported lifestyle intervention on clinical pregnancy outcomes or health behavioural outcomes was not examined by either study. The second internetsupported intervention identified by the current systematic review, ‘eMOMS of Rochester’39 is currently ongoing with no results published to date. Therefore, although there is insufficient evidence as to the effectiveness of internet-supported interventions, the two completed studies42,43 demonstrate the importance of making lifestyle interventions accessible to the target population, and the importance of strategies to promote continued engagement with the healthy lifestyle programme. App-supported lifestyle interventions in pregnancy. The current review identified no completed, published literature that evaluates the use of a smart phone app as a means of, or an adjunct to, lifestyle intervention in pregnancy. However, despite the novelty of the area, two ongoing RCTs were identified: ‘SmartMoms’40 and ‘MOTHER’,41 which have estimated primary outcome completion dates set for September 2016 and June 2014, respectively. The outcome measures for ‘SmartMoms’ include both clinical pregnancy outcomes as well as health behavioural outcomes. However, ‘MOTHER’, which was designed as a pilot trial, aims to evaluate physical activity level only, which, although an important healthy behaviour measure in pregnancy, is less objective a measure than clinical pregnancy outcomes. Therefore, at this time, there is no evidence to either support or contest the use of smart phone apps in lifestyle interventions during pregnancy. DISCUSSION The findings of the current review highlight several important points. They suggest that technology-supported lifestyle interventions in pregnancy hold potential as a safe and sustainable adjunct to traditional health-care models. However, both the quality and quantity of published evidence to support the use of such interventions is low, particularly data examining more modern technologies such as smart phone apps. Findings also raise the issue of uptake levels and socio-cultural acceptance of such lifestyle interventions. Quality and quantity of literature The studies included in the current review highlight the absence of data examining the effect of technology-supported lifestyle interventions in pregnancy on important pregnancy outcomes such as maternal and fetal complications. Maternal GWG is, however, dealt with in some studies that were included. This is a positive finding, as previous studies10,45–48 have demonstrated a strong association between lifestyle interventions during pregnancy and healthier GWG. It is clear that, although there is a substantive body of literature examining technology’s effect on healthy lifestyle interventions 'outside of' pregnancy,49–57 robust research into the effects of technologysupported interventions in pregnancy on clinical and behavioural outcomes is in its infancy. This is evidenced by the focus on intervention acceptance measures42,43 rather than clinical outcome measures; use of small sample sizes;38,41 lack of demonstration of causality; and lack of examination of long-term effects or follow-up,37,38,40,41 which has been shown to be key for successful lifestyle change.58 It is important that the same © 2014 Macmillan Publishers Limited

research interest in technology-supported lifestyle interventions is mirrored for the antenatal period, namely through publication of well-designed, sufficiently powered RCTs to build on the current preliminary research findings. Effectiveness of technology-supported lifestyle interventions in pregnancy Accessibility and cost-effectiveness. The financial cost of antenatal care has been shown to rise proportionally with maternal body weight,59 by 5%, 21% and 34% for overweight and obese women and those who develop GDM, respectively. Application of communication technologies has the potential to deliver widespread healthy lifestyle education to these at-risk groups and further amplify the positive outcomes observed in healthy lifestyle interventions in pregnancy.10,45–48 The use of such technology has already been successfully demonstrated outside pregnancy as a potential means of disseminating tailored nutrition information and as an effective adjunct to traditional counselling methods,49–57 as it may be possible to reach more people, costing considerably less than would be possible with traditional counselling methods.60,61 This could potentially decrease the strain on resources such as time, finance and staff. Furthermore, the potential market for technology-supported lifestyle interventions is sizable and rapidly expanding. A global survey62 of 44 countries found that worldwide smart phone ownership almost doubled in 1 year from 19% in 2010 to 35% in 2011. Widespread internet access is increasingly available, as evidenced by 70–85% of the Irish and British population. Approximately 69–77% of Irish 16–34-year-olds own a smart phone,63 which includes the prime child-bearing years for women, ~ 50% of whom are overweight or obese6 and considered an at-risk population. A growing body of evidence also documents the potentially beneficial impact of technology on improving nutrition education in women of lower socio-economic status,64 and those with health literacy and numeracy difficulties.65 Therefore, potential cost savings, widespread accessibility for many socio-economic groups and large market potential make technology-supported interventions an attractive adjunct to face-to-face care. Safety of technology-supported lifestyle interventions in pregnancy. None of the studies included in the current review identified any harmful or dangerous effects associated with the use of communication technologies in lifestyle interventions.37–43 However, the introduction of modern communication technology into clinical practice carries with it several risks, particularly lack of evidence and regulation of the information provided to patients.60,66,67 Search strategies used in the current review yielded minimal published results examining the more modern technologies such as smart phone apps40,41 and internet-based technologies,39,42,43 and no completed trials evaluating the effectiveness of such interventions. This is a cause for major concern, considering the abundance of seemingly unregulated and un-evidenced online and app-based lifestyle advice that is available to pregnant women, which may not have been tested for safety and efficacy.60,66 This is particularly concerning for the antenatal population, which is, as described previously, highly motivated and open to behavioural change,24–26 and therefore particularly vulnerable to misinformation found in unregulated apps. Both the Food and Drug Administration (USA) and the Medications and Healthcare Products Regulatory Agency (UK) have taken preliminary steps to improve app regulation,51,67 although no formal evaluation is currently performed on a regular basis. To date, there is a lack of information available in the literature regarding the safety of patients using medical or lifestyle apps.51,60,66,67 Thus, it is imperative that future app-supported lifestyle interventions on smart phones be based on well-powered RCTs to provide an evidence-based underpinning to real-life clinical practice. European Journal of Clinical Nutrition (2014) 760 – 766

Technology lifestyle interventions in pregnancy OA O’Brien et al

764 Table 2.

Summary of results and conclusions of studies included in the systematic review

Publication Nagle et al.

Primary outcome results 37

Jackson et al.38

NCT0133156439

Secondary outcome results

Conclusions

Ongoing

NA

NA

In the Video Doctor group, there were statistically significant increases from baseline in exercise (P o 0.05), intake of fruits and vegetables (P = 0.001), whole grains (P = 0.001), fish (P o 0.05), avocado and nuts (P = 0.003), and significant decreases in intake of sugary foods (P o 0.05), refined grains (P o 0.05), high-fat meats (P o 0.05), fried foods (P o 0.001), solid fats (P o 0.001) and fast food (P o 0.05). No changes from baseline for any of these outcomes in the usual care group

Nutrition knowledge improved significantly more in the Video Doctor group (P = 0.009). Clinician–patient discussions about these topics occurred significantly more frequently in the Video Doctor group (P o 0.0005). No difference in weight gain between groups (P = 0.91)

A brief Video Doctor intervention can improve exercise and dietary behaviours and nutritional knowledge in pregnant women, but is unlikely to significantly influence GWG

Ongoing

NA

NA

Uptake of programme was 17% (n = 238) Significantly more lower- compared with higherMost women were highly educated (68%) educated women discontinued using it (P = 0.02) and already had a healthy lifestyle About half of them (52%) continued to use the programme throughout their pregnancy

The programme did not reach a substantial proportion of the target population Disadvantaged women are less likely to use the programme and more likely to discontinue using it

Bot et al.43

About 8% of pregnant women in The Netherlands enrolled in the programme Immigrants and women with a low level of education were under-represented Most women knew about the programme from a promotional email sent by the organisation (32%), followed by the Internet (22%) and midwives (16%)

Women with little education were more often inactive users of the programme compared with highly educated women (P o 0.001)—the most active users (P o 0.001) Women with less education were more likely to highly appreciate the programme (P = 0.001)

The programme did not reach a substantial proportion of the Dutch population On a population level, disadvantaged women are still less likely to use the programme and more likely to discontinue using it

NCT0161075240

Ongoing Est. completion date: September 2016

NA

NA

NCT0146170741

Ongoing Est. completion: date June 2014

NA

NA

Van Zutphen et al.

42

Abbreviations: CI, confidence interval; Est., estimated; GWG, gestational weight gain; n, number of subjects; NA, not applicable; P, statistical significance.

Uptake and acceptance of technology-supported lifestyle interventions in pregnancy. Both the internet- and video-supported lifestyle interventions included in the current review identified the difficulty of developing culturally appropriate adaptions of interventions as a barrier to national level implementation,38,42,43 identifying women of lower socio-economic status as a being less likely to engage with healthy lifestyle behaviours and more likely to drop out of such interventions. These poor levels of uptake and acceptance reiterate the findings of many public health studies,68,69 which have found a clustering of significantly less favourable diet, health behaviours and participation in health promotion programmes among lower socio-economic groups, whose long-term health is typically poorer than that of their higher socio-economic counterparts. It is already known that women of lower socio-economic status can potentially receive lifestyle interventions through communication technologies, ownership of which has been previously demonstrated across all socio-economic strata.64,65 However, socio-cultural acceptance of such interventions must also be addressed. As previously mentioned, lifestyle interventions have been found to be more successful when they are adapted appropriately for their intended target group.70 This has various implications for practice, whereby lifestyle interventions must be fully comprehensible for all education and income levels, religions, races and cultures.71 Future research in this area should focus on effective methods for increasing enrolment and continued engagement in technologysupported lifestyle interventions in pregnancy, particularly internet-supported lifestyle interventions, which have previously been found to have significantly higher attrition rates than other education delivery methods.56,72,73 European Journal of Clinical Nutrition (2014) 760 – 766

Strengths and limitations This is the first review of its kind in this area. It adds to the sparse but growing body of evidence examining the use of technologysupported lifestyle interventions in pregnancy. The review is strengthened by the broad search strategy used, such as multiple data sources and consideration of both completed and ongoing trials. The PRISMA review methodology36 was adopted in order to minimise bias. Furthermore, relevant clinical outcomes such as GWG, incidence of GDM diagnosis and birthweight were used where available. The review was limited by several factors. The evidence summarised in the current work comes from available studies of which some were merely intended as feasibility or acceptance studies, and of which three are currently ongoing. Finally, the intensity and duration of the interventions of trials varied and trials were predominantly based in the United States, a phenomenon common to many obesity-related reviews. Conclusions and future research The findings of the current systematic review indicate that communication technology holds potential as a safe and sustainable therapeutic tool for the support of lifestyle interventions in pregnancy. However, the evidence base is weak, particularly in support of more modern technologies such as smart phone apps and internet, which hold the most promise for interactive, practical, accessible and instantaneous support. Further RCTs on the effectiveness of the use of communication technology are required, particularly among those most likely to benefit from lifestyle interventions, such as overweight and obese pregnant women, and should focus on: © 2014 Macmillan Publishers Limited

Technology lifestyle interventions in pregnancy OA O’Brien et al

765 (i) Evaluating the outcome of technology-supported lifestyle interventions on both clinical and health behavioural pregnancy outcomes in ‘real-life’ clinical settings. (ii) Evaluating cost-effectiveness and potential cost savings for antenatal care. (iii) Determining both levels of uptake and socio-cultural acceptance of technology-supported lifestyle interventions on population subgroups—for example, ethnic groups, younger women, low socio-economic status groups.

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CONFLICT OF INTEREST The authors declare no conflict of interest.

ACKNOWLEDGEMENTS The work was financially supported by the National Maternity Hospital (NMH) medical fund. It was carried out as part of an MSc programme at NMH where OOB is an MSc student working in the area of maternal nutrition during pregnancy, and whose post is funded by the NMH medical fund.

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AUTHOR CONTRIBUTIONS OOB wrote the article, and the draft was discussed with and revised by FMM, MMC and EG. 28

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