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IMiD, Wydawnictwo Aluna

Medycyna Wieku Rozwojowego, 2012, XVI, 3

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Wlodek Lopaczynski, MD, PhD
National Institutes of Health, Bethesda, Maryland, USA
Abstract
Recently, scientific literature informed that metabolic conditions in pregnant women may be associated with increased risk
for autism and other neurodevelopmental disorders in their offspring. In a cohort study of more than 1000 children between
the ages of 2 and 5 years, those who had mothers classified as having "metabolic conditions" (which included diabetes,
hypertension, and obesity) during pregnancy were at a significantly higher risk for developing an autism spectrum disorder
(ASD) and neurodevelopmental delays. In addition, mothers with obesity were 1.6 times more likely to have a child with ASD
and more than twice as likely to have a child with other developmental problems. In the United States, the prevalence of
obesity among women of childbearing age is 34%. Moreover, with obesity rates rising steadily, these results appear to raise
serious public health implications. The main objective of this Editorial is to propagate the health care improvement based on
the translation research approach from basic behavioral sciences and relevant integrative neuroscience to pressing clinical
issues that include an understanding of the etiology and assessment of disorders, and the assessment of functioning and development of innovative and culturally appropriate preventive treatment. Behavioral interventions for weight management
in pregnancy may include the Transtheoretical Model (TTM) employed in obese pregnant women and then, the comparison
with elements of the ecological model. A comparative effectiveness design is to test the effect of tailoring while including one
of the most important predictors of screening-physician recommendation: after careful selection of analyzed behaviors from
the TTM approach. However, there is also a risk that the evidence may not be conclusive for sustained weigh loss as a primary
outcome of the proposed intervention, although the TTM in combination of physical activity and diet tended to produce significant results. Therefore, physicians might use the TTM to convince pregnant women to regulate weight and educate future
parents on how to deal with autism at an early age of their children using watchful waiting management.
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The increasing importance of translational research


by applying specific approaches in order to improve
human health and well-being is helping to bridge the
gaps among science, policy and practice. In general,
translational research refers to the bench-to-bedside
enterprise of harnessing knowledge from basic science
to produce new drugs, devices, and intervention options
for patients. For this area of research, the end point
is the production of a promising new treatment that
can be clinically used. However, for others, especially
health services and public health researchers whose
studies focus on health care and health as the primary
outcome, the translational research refers to translating
science into practice by ensuring that new interventions
or treatments and research knowledge actually reach
populations for whom they are intended and adequately
implemented. The purpose of this Editorial is to propagate
the translation of work from basic behavioral science

and relevant integrative neuroscience research by pressing issues regarding some aspects of clinical disorders,
including: an understanding of the etiology and assessment of disorders; the assessment of functioning; the
development of innovative and culturally appropriate
preventive treatment and rehabilitation interventions;
and improvement of methods for the effective delivery
of public health services. I also intended to encourage
behavioral scientists to seek further understanding of
behavioral processes through an exploration of how those
processes are altered by mental and behavioral disorders
to transcend the barriers of disciplines in research and
institution settings in order to harness the full range of
modern behavioral sciences to service of the critical
health needs. For this purpose, I will summarize briefly
some recent studies related to this topic.
Historically, improving the dietary health of nations
that are fighting obesity has been a long-standing goal

*This article was prepared by Dr. Lopaczynski in his personal capacity. The opinions expressed in this article are the author's own and do
not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government.

172

Editorial

of healthcare researchers and practitioners, as well as


many governments. For example, in the United States
of America (U.S.), about half of women of reproductive age are either overweight, or obese. Additionally,
according to the American Pregnancy Association,
there are approximately 6 million pregnancies every
year throughout the U.S. Although most obese women
will have a good overall obstetric outcome, obesity has
been a major predictor of maternal mortality and has
resulted in major complications according to recent
studies (1). Major complications associated with obesity include: subfertility, fetal macrosomia, hypertensive
disorders of pregnancy, prolonged labor, gestational
diabetes, Cesarean birth and associated anesthetic and
surgical complications, congenital malformations, and
first trimester spontaneous abortion. Recently, scientific
literature informed that metabolic conditions in obese
pregnant women may be associated with increased risk
for autism and other neurodevelopmental disorders in
their offspring. In a cohort study of over 1000 children
between the ages of 2 and 5 years, those who had mothers classified as having "metabolic conditions" (which
included diabetes, hypertension, and obesity) during
pregnancy were at a significantly higher risk of developing
an autism spectrum disorder (ASD) and neurodevelopmental delays than the children with mothers who
did not have metabolic conditions. Also, mothers who
were obese were 1.6 times more likely to have a child
with ASDs and more than twice as likely to have a child
with other developmental problems (2). However, no
statistically significant associations were found between
overt diabetes and ASD, or between hypertension and
ASD or developmental delays.
For a significant time, the Transtheoretical Model
(TTM) stages of change have been considered a useful
interventional approach in lifestyle modification programs,
including weight loss management for overweight and
obese adults (3). Also, mastering behaviors related to
nutrition, physical activity and weight management are
the main issues in obese pregnant women. Thus, these
approaches can be also recommended for both efficacy and
cost-effectiveness, and TTM intervention can be tailored
to test the needs of individuals while treating the entire
population of pregnant women with obesity. Before the
intervention, associations have to be assessed between
measures used by health care services and Body Mass
Index (BMI, defined as the weight in kilograms divided
by the square of the height in meters), to categorize the
pregnant women as underweight (BMI<18.5), normal
(BMI 18.5 to 24.9), overweight (BMI 25.0 to 29.9), or
obese (BMI>30.0). Finally, the intervention using the
TTM approach can provide a foundation for the development of more effective behavioral interventions
utilizing the social ecological model.
Briefly, obesity is a global public health issue and the
TTM model for dietary and physical exercise modification

in weight loss management for overweight and obese


adults has been often useful; however, its effectiveness
in producing sustainable weight loss in such individuals
has been found to vary considerably (3). Although TTM
may apply across at least 48 behaviors and populations
from many countries, the model still has some general
limitations (4). In addition, decisional balance (4), which
reflects an individual pregnant woman with obesity,
the pros and cons of changing, are also expected to be
observed during this intervention. However, there is
concern about self-efficacy, including confidence, and
there is also a high risk that there can be no conclusive
evidence for sustained weight loss as a primary outcome
of the proposed intervention (3). Nonetheless, the TTM
may be especially useful in developing healthy behavior
for pregnant women with obesity, as well as - at the same
time - physicians might use the TTM to convince pregnant
women to regulate weight and educate future parents on
how to deal with autism at an early age (2-5 years) of their
children. This TTM approach can be applied in many
settings, including primary care, obstetric/gynecological offices, homes, churches, and some communities or
worksites. In addition, the initial intervention using the
TTM approach can provide background for the development of more specific approaches utilizing the ecological
model, including the intervention that is designed after
careful selection of one most promising behavior from
a tailored intervention. Particularly, pregnant women
with BMI >30 should be selected for this intervention.
Recent studies from a British research group (5) claim
that despite intense and often tailored behavioral interventions for weight management in pregnancy, there is
no statistically significant healthy management reported
in qualitative studies, which was addressed so far in the
interventions, but this in itself was insufficient to lead
to reduce weight in pregnant obese women. Therefore,
potential interventions should be focused on these women
to address the impact of changes in incentives for BMI
reduction during pregnancy.
On the other hand, while there is much hope and
anticipation in the ASD professional and parent communities, which increased public awareness, currently
many barriers to early and appropriate diagnosis and
treatment still remain (6). Importantly, distinguishing
between cognitive or language delays and social communication delays in ASD may be subtle and not easily
recognized. However, parents can be the best resource
for identifying young children whose development and
behavior appear atypical. Also, parents who bring concerns to a pediatrician have been shown to be the primary
cause of identification of many medical and behavioral
conditions diagnosed at health supervision visits (7).
The need for parental input, particularly regarding the
diagnosis of ASDs, has been impressively illustrated in
books for and by parents of children with ASDs (6, 8).
These books and other media are likely to improve par-

Editorial

ents' knowledge and observational skills. This increased


awareness should improve identification of aberrations
in typical development and behavior to advance early
identification of ASD. Thus, the final step in identifying
ASD may include watchful waiting (also called: watch
and wait, expectant management, or active surveillance
(9) ), which needs to be applied to the entire study cohort
in a pediatric/family practice office as a recommended
approach to diagnose ASD in children with a medical
problem related to obesity during the mothers pregnancy.
Obviously, during that time, repeated testing for ASD must
be only performed by qualified medical personnel. This
kind of intervention builds on prior research, including
studies that demonstrate the advantage of tailored interventions as compared to generic or targeted designs (10).
In the time of ever-expanding knowledge about and
intense focus on autism, there is a major concern on
how pediatricians should respond to parental concerns.
Though pediatricians may not always have the answers,
they will not go wrong if they listen to parents and acknowledge their concerns. The message "wait and see"
is understandably a battle cry to parents who worry that
their children have true delays. Children with atypical
social/emotional development as toddlers may ultimately
be diagnosed with ASD, a language disorder, cognitive
delay, sensory integration dysfunction, attention-deficit/
hyperactivity disorder, or merely a challenging temperament by the time they are school aged. In the face of
parental concern, the critical issue for pediatricians is to
distinguish children with a problem requiring an immediate, intensive intervention from one for whom watchful
waiting is appropriate. Additionally, a key component of
watchful waiting is the use of an explicit decision tree
or other protocols to ensure a timely transition from
watchful waiting to another form of management, as
needed. This is particularly common in postsurgical
management of cancer survivors, in whom cancer recurrence is a significant concern.
Although there was a relationship between obesity
and autism, the concept itself is obviously controversial
since there was also a very modest association found
between the developmental disorders and diabetes
(2). For example, Dr. Max Wiznitzer, who is also the
neurology liaison to the Autism Subcommittee for the
American Academy of Pediatrics, recently stated that the
real question is about the interpretation of Krakowiaks
results (CNN Health, April, 2012). For example, obese
women have an increased risk for pregestational diabetes, which may be undiagnosed before pregnancy. Also,
there is concern about whether the found association
with autism is causal, or there is a maternal factor that
is contributing to the obesity, which then increases the
risk of developmental problems, including autism. At this
point, we need more information and the study needs
to be replicated. Nonetheless, Dr. Wiznitzer noted that if
the study's results can influence women to better man-

173

age their weight and overall health before and during


pregnancy, this would be a major strength.
Indeed, this kind of intervention can start in response
to parental concerns. Pediatricians should acknowledge
and address parents with concrete advice for how to
promote a child's development, whether or not the child
has a specific diagnosis. Although the parents of children
with developmental delays often request guidance on
how to interact more effectively with their children, a
pediatrician's goal should be to place the child's behaviors in a clinical framework and to offer strategies
that work within this exact framework. In the case of a
child with a difficult temperament, such as being slow
to warm up or having a negative mood or impulsive/
emotional liability, this may begin with a discussion of
the concept of temperament, administration of a temperament scale to the parent and child, and discussion
of "goodness of fit" (11). For the child with socialization
delays, this may involve a referral to Early Intervention
(federally mandated service for children with disabilities),
a play group, or introducing the parents to Greenspan
and Wieders (12) concept of "floortime" and "closing
circles of communication", so that they can begin this
intervention at home. Parents of children whose language acquisition seems questionable for their age can
be advised to use picture books to name objects, tell
stories, point and name common objects in the home,
and provide an ongoing description of their activities.
Picture books also provide a vehicle for parents to support joint attention. A close clinical follow-up how the
child responds to these interventions may be informative diagnostically, but clinical presentation is initially
unclear. While suggesting these activities, clinicians who
recognize delays in behavior, socialization, and communication need to raise the possibility of ASD and
make appropriate referrals for developmental, speech,
language, and audiological assessments. Encouraging
parents to become their child's primary therapist is not
appropriate. Parents need tools so that they can interact
with, understand, and advocate for their child, but the
onus for appropriate referral, diagnosis, and treatment
lies with the pediatric provider.
In conclusion, using the translational research approaches we may close that gap and improve health
care quality by improving access, reorganizing and
coordinating systems of care, helping clinicians and
patients to change behaviors and make more informed
choices, providing reminders and point-of-care decision
support tools, and strengthening the patient-clinician
relationship.

REFERENCES
1. Stotland N.E.: Obesity and pregnancy. BMJ 2008; 337: a2450.
2. Krakowiak P., Walker C.K., Bremer A.A., Baker A.S., Ozonoff
S., Hansen R.L., Hertz-Picciotto I.: Maternal metabolic

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Editorial

conditions and risk for autism and other neurodevelopmental


disorders. Pediatrics 2012; 129: e1121-e1128.
3. Tuah N.A., Amiel C., Qureshi S., Car J., Kaur B., Majeed A.:
Transtheoretical model for dietary and physical exercise
modification in weight loss management for overweight
and obese adults. Cochrane Database Syst Rev 2011; (10):
CD008066. (Issue 2-2012).
4. Prochaska J.O., Redding C.A., Evers K.E.: The transtheoretical
model and stages of change. In: Glanz K, Rimer BK, Viswanath
K (Eds). Health Behavior and Health Education. Theory,
Research, and Practice. Jolley-Bass, San Francisco, CA, 2008.
5. Campbell F., Johnson M., Messina J., Guillaume L., Goyder
E.: Behavioural interventions for weight management in
pregnancy: a systemic review of quantitative and qualitative
data. BMC Public Health 2011; 11: 491-506.
6. Wiseman N.D.: Autism: A Parent's Guide to the First Signs
and Next Steps. Broadway Books, New York, NY, 2006.
7. Glascoe F.P.: Parents' evaluation of developmental status:
how well do parents' concerns identify children with
behavioral and emotional problems? Clin Pediatr (Phila)
2003; 42: 133-138.

8. Senator S.: Making Peace with Autism: One Family's Story


of Struggle, Discovery, and Unexpected Gifts. Trumpeter,
Boston, Mass., 2005.
9. Meredith L.S., Cheng W.J., Hickey S.C., Dwight-Johnson
M.: Factors associated with primary care clinicians' choice
of a watchful waiting approach to managing depression.
Psychiatr Serv 2007; 58: 72-78.
10. Hawkins R.P., Kreuter M., Resnicow K., Fishbein M., Dijkstra
A.: Understanding tailoring in communicating about health.
Health Educ Res 2008; 23: 454-466.
11. Chess S., Thomas A.: Temperament in Clinical Practice.
Guilford Press, New York, NY, 2005.
12. Greenspan S., Wieder S.: Engaging Autism: Helping Children
Relate, Communicate and Think with the DIR Floortime
Approach. Da Capo Press, Cambridge, Mass., 2006.

Received: September 10, 2012


Accepted: September 17, 2012

Address for correspondence:


Wlodek Lopaczynski
8120 Paisley Place
Potomac, MD 20854
E-mail: wlopaczynski@hotmail.com

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