Underreporting of Energy Intake Increases over Pregnancy: An Intensive Longitudinal Study of Women with Overweight and Obesity.

(1) Background: Energy intake (EI) underreporting is a widespread problem of great relevance to public health, yet is poorly described among pregnant women. This study aimed to describe and predict error in self-reported EI across pregnancy among women with overweight or obesity. (2) Methods: Participants were from the Healthy Mom Zone study, an adaptive intervention to regulate gestational weight gain (GWG) tested in a feasibility RCT and followed women (n = 21) with body mass index (BMI) ≥25 from 8−12 weeks to ~36 weeks gestation. Mobile health technology was used to measure daily weight (Wi-Fi Smart Scale), physical activity (activity monitor), and self-reported EI (MyFitnessPal App). Estimated EI was back-calculated daily from measured weight and physical activity data. Associations between underreporting and gestational age, demographics, pre-pregnancy BMI, GWG, perceived stress, and eating behaviors were tested. (3) Results: On average, women were 30.7 years old and primiparous (62%); reporting error was −38% ± 26 (range: −134% (underreporting) to 97% (overreporting)), representing an ~1134 kcal daily underestimation of EI (1404 observations). Estimated (back-calculated), but not self-reported, EI increased across gestation (p < 0.0001). Higher pre-pregnancy BMI (p = 0.01) and weekly GWG (p = 0.0007) was associated with greater underreporting. Underreporting was lower when participants reported higher stress (p = 0.02) and emotional eating (p < 0.0001) compared with their own average. (4) Conclusions: These findings suggest systemic underreporting in pregnant women with elevated BMI using a popular mobile app to monitor diet. Advances in technology that allow estimation of EI from weight and physical activity data may provide more accurate dietary self-monitoring during pregnancy.

Variation in urine osmolality throughout pregnancy: a longitudinal, randomized-control trial among women with overweight and obesity.

PURPOSE: Water needs increase during pregnancy, and proper hydration is critical for maternal and fetal health. This study characterized weekly hydration status changes throughout pregnancy and examined change in response to a randomized, behavioral intervention. An exploratory analysis tested how underhydration during pregnancy was associated with birth outcomes. METHODS: The Healthy Mom Zone Study is a longitudinal, randomized-control trial intervention aiming to regulate gestational weight gain (GWG) in pregnant women with overweight/obesity (n = 27). Fourteen women received standard of care; 13 women additionally received weekly guidance on nutrition, physical activity, water intake, and health-promoting behaviors. Hydration status was measured weekly via overnight urine osmolality (Uosm) from ~ 8-36 weeks gestation; underhydration was dichotomized (Uosm ≥ 500 mOsm/kg). Gestational age- and sex-standardized birth weight and length z scores and percentiles were calculated. We used mixed-effect and linear regression models to test covariate-adjusted relationships. RESULTS: No differences existed in Uosm or other characteristics between control and intervention women at baseline. Significant interactions (p = 0.01) between intervention and week of pregnancy on Uosm indicated intervention women maintained lower Uosm, whereas control women had a significant quadratic (inverse-U) relationship and greater Uosm in the second and early third trimesters. Results were consistent across robustness and sensitivity checks. Exploratory analyses suggest underhydration was associated with birth weight, but not length, in opposite ways in the second vs. third trimester. CONCLUSION: A multi-component behavioral intervention helped women with overweight/obesity maintain better hydration throughout pregnancy. Future studies should confirm birth outcome results as they have important implications for early life nutrition. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03945266; registered May 10, 2019 retrospectively.

Urinary cortisol is lower in pregnant women with higher pre-pregnancy BMI.

Background/objectives: Although cortisol levels increase during normal pregnancy, particularly high levels of cortisol or stress have been associated with adverse maternal/child outcomes. Obesity is associated with altered cortisol metabolism, but there is limited information on pregnancy-related changes in cortisol in pregnant women with overweight/obesity. The objective of this study was to examine weekly measures of urinary cortisol and perceived stress throughout ~10-36 weeks gestation, if levels differ by pre-pregnancy BMI categories, and whether concurrent measures of urinary cortisol and perceived stress are associated. Methods: Longitudinal observational data from Healthy Mom Zone, a gestational weight management intervention, and an ancillary fetal growth study were combined. Pregnant women with normal (n=7), overweight (n=11), or obese (n=14) pre-pregnancy BMI were recruited at >8 weeks gestation. Overnight urinary cortisol and Perceived Stress Scale were measured weekly from ~10-36 weeks gestation. Results: Higher pre-pregnancy BMI was associated with overall lower urinary cortisol throughout gestation, but rate of increase in urinary cortisol across pregnancy was similar across weight status groups. Women with obesity reported higher levels of overall perceived stress than normal weight women. Regardless of weight status, perceived stress was not associated with gestational age or cortisol. Conclusions: Although women with obesity reported higher perceived stress, they had lower urinary cortisol than women with normal BMI, and gestation-related increases in cortisol were similar across weight groups and unrelated to perceived stress, suggesting that physiological factors that drive increases in cortisol as pregnancy may outweigh effects of stress and adiposity. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT03945266, identifier (NCT03945266).

Adaptive, behavioral intervention impact on weight gain, physical activity, energy intake, and motivational determinants: results of a feasibility trial in pregnant women with overweight/obesity.

Interventions have modest impact on reducing excessive gestational weight gain (GWG) in pregnant women with overweight/obesity. This two-arm feasibility randomized control trial tested delivery of and compliance with an intervention using adapted dosages to regulate GWG, and examined pre-post change in GWG and secondary outcomes (physical activity: PA, energy intake: EI, theories of planned behavior/self-regulation constructs) compared to a usual care group. Pregnant women with overweight/obesity (N = 31) were randomized to a usual care control group or usual care + intervention group from 8 to 2 weeks gestation and completed the intervention through 36 weeks gestation. Intervention women received weekly evidence-based education/counseling (e.g., GWG, PA, EI) delivered by a registered dietitian in a 60-min face-to-face session. GWG was monitored weekly; women within weight goals continued with education while women exceeding goals received more intensive dosages (e.g., additional hands-on EI/PA sessions). All participants used mHealth tools to complete daily measures of weight (Wi-Fi scale) and PA (activity monitor), weekly evaluation of diet quality (MyFitnessPal app), and weekly/monthly online surveys of motivational determinants/self-regulation. Daily EI was estimated with a validated back-calculation method as a function of maternal weight, PA, and resting metabolic rate. Sixty-five percent of eligible women were randomized; study completion was 87%; 10% partially completed the study and drop-out was 3%. Compliance with using the mHealth tools for intensive data collection ranged from 77 to 97%; intervention women attended > 90% education/counseling sessions, and 68-93% dosage step-up sessions. The intervention group (6.9 kg) had 21% lower GWG than controls (8.8 kg) although this difference was not significant. Exploratory analyses also showed the intervention group had significantly lower EI kcals at post-intervention than controls. A theoretical, adaptive intervention with varied dosages to regulate GWG is feasible to deliver to pregnant women with overweight/obesity.

Validation of a Classroom Version of the Eating in the Absence of Hunger Paradigm in Preschoolers.

Eating in the absence of hunger (EAH), a measure of children's propensity to eat beyond satiety in the presence of highly palatable food, has been associated with childhood obesity and later binge eating behavior. The EAH task is typically conducted in a research laboratory setting, which is resource intensive and lacks ecological validity. Assessing EAH in a group classroom setting is feasible and may be a more efficient alternative, but the validity of the classroom assessment against the traditional individually-administered paradigm has not been tested. The objective of this study was to compare EAH measured in a classroom setting to the one-on-one version of the paradigm in a sample of Head Start preschoolers. Children (n = 35) from three classrooms completed both classroom and individual EAH tasks in a random, counterbalanced order. In the group condition, children sat with peers at their classroom lunch tables; in the individual condition, children met individually with a researcher in a separate area near their classroom. In both conditions, following a meal, children were provided free access to generous portions of six snack foods (~750 kcal) and a selection of toys for 7 min. Snacks were pre- and post-weighed to calculate intake. Parents completed a survey of their child's eating behaviors, and child height and weight were measured. Paired t-tests and intraclass correlation coefficients were used to compare energy intake between conditions, and correlations between EAH intake and child BMI, eating behaviors, and parent feeding practices were examined to evaluate concurrent validity. Average intake was 63.0 ± 50.4 kcal in the classroom setting and 53.7 ± 44.6 in the individual setting, with no significant difference between settings. The intraclass correlation coefficient was 0.57, indicating moderate agreement between conditions. Overall, the EAH protocol appears to perform similarly in classroom and individual settings, suggesting the classroom protocol is a valid alternative. Future studies should further examine the role of age, sex, and weight status on eating behavior measurement paradigms.

Short Nighttime Sleep Duration and High Number of Nighttime Awakenings Explain Increases in Gestational Weight Gain and Decreases in Physical Activity but Not Energy Intake among Pregnant Women with Overweight/Obesity.

Pregnant women are at a high risk for experiencing sleep disturbances, excess energy intake, low physical activity, and excessive gestational weight gain (GWG). Scant research has examined how sleep behaviors influence energy intake, physical activity, and GWG over the course of pregnancy. This study conducted secondary analyses from the Healthy Mom Zone Study to examine between- and within-person effects of weekly sleep behaviors on energy intake, physical activity, and GWG in pregnant women with overweight/obesity (PW-OW/OB) participating in an adaptive intervention to manage GWG. The overall sample of N = 24 (M age = 30.6 years, SD = 3.2) had an average nighttime sleep duration of 7.2 h/night. In the total sample, there was a significant between-person effect of nighttime awakenings on physical activity; women with >1 weekly nighttime awakening expended 167.56 less physical activity kcals than women with <1 nighttime awakening. A significant within-person effect was also found for GWG such that for every increase in one weekly nighttime awakening there was a 0.76 pound increase in GWG. There was also a significant within-person effect for study group assignment; study group appeared to moderate the effect of nighttime awakenings on GWG such that for every one increase in weekly nighttime awakening, the control group gained 0.20 pounds more than the intervention group. There were no significant between- or within-person effects of sleep behaviors on energy intake. These findings illustrate an important need to consider the influence of sleep behaviors on prenatal physical activity and GWG in PW-OW/OB. Future studies may consider intervention strategies to reduce prenatal nighttime awakenings.

Uncontrolled Eating during Pregnancy Predicts Fetal Growth: The Healthy Mom Zone Trial.

Excess maternal weight gain during pregnancy elevates infants' risk for macrosomia and early-onset obesity. Eating behavior is also related to weight gain, but the relationship to fetal growth is unclear. We examined whether Healthy Mom Zone, an individually tailored, adaptive gestational weight gain intervention, and maternal eating behaviors affected fetal growth in pregnant women (n = 27) with a BMI > 24. At study enrollment (6-13 weeks gestation) and monthly thereafter, the Three-Factor Eating Questionnaire was completed. Ultrasounds were obtained monthly from 14-34 weeks gestation. Data were analyzed using multilevel modeling. Higher baseline levels of uncontrolled eating predicted faster rates of fetal growth in late gestation. Cognitive restraint was not associated with fetal growth, but moderated the effect of uncontrolled eating on fetal growth. Emotional eating was not associated with fetal growth. Among women with higher baseline levels of uncontrolled eating, fetuses of women in the control group grew faster and were larger in later gestation than those in the intervention group (study group × baseline uncontrolled eating × gestational week interaction, p = 0.03). This is one of the first intervention studies to use an individually tailored, adaptive design to manage weight gain in pregnancy to demonstrate potential effects on fetal growth. Results also suggest that it may be important to develop intervention content and strategies specific to pregnant women with high vs. low levels of disinhibited eating.

Individually Tailored, Adaptive Intervention to Manage Gestational Weight Gain: Protocol for a Randomized Controlled Trial in Women With Overweight and Obesity.

BACKGROUND: High gestational weight gain is a major public health concern as it independently predicts adverse maternal and infant outcomes. Past interventions have had only limited success in effectively managing pregnancy weight gain, especially among women with overweight and obesity. Well-designed interventions are needed that take an individualized approach and target unique barriers to promote healthy weight gain. OBJECTIVE: The primary aim of the study is to describe the study protocol for Healthy Mom Zone, an individually tailored, adaptive intervention for managing weight in pregnant women with overweight and obesity. METHODS: The Healthy Mom Zone Intervention, based on theories of planned behavior and self-regulation and a model of energy balance, includes components (eg, education, self-monitoring, physical activity/healthy eating behaviors) that are adapted over the intervention (ie, increase in intensity) to better regulate weight gain. Decision rules inform when to adapt the intervention. In this randomized controlled trial, women are randomized to the intervention or standard care control group. The intervention is delivered from approximately 8-36 weeks gestation and includes step-ups in dosages (ie, Step-up 1 = education + physical activity + healthy eating active learning [cooking/recipes]; Step-up 2 = Step-up 1 + portion size, physical activity; Step-up 3 = Step-up 1 + 2 + grocery store feedback, physical activity); 5 maximum adaptations. Study measures are obtained at pre- and postintervention as well as daily (eg, weight), weekly (eg, energy intake/expenditure), and monthly (eg, psychological) over the study period. Analyses will include linear mixed-effects models, generalized estimating equations, and dynamical modeling to understand between-group and within-individual effects of the intervention on weight gain. RESULTS: Recruitment of 31 pregnant women with overweight and obesity has occurred from January 2016 through July 2017. Baseline data have been collected for all participants. To date, 24 participants have completed the intervention and postintervention follow-up assessments, 3 are currently in progress, 1 dropped out, and 3 women had early miscarriages and are no longer active in the study. Of the 24 participants, 13 women have completed the intervention to date, of which 1 (8%, 1/13) received only the baseline intervention, 3 (23%, 3/13) received baseline + step-up 1, 6 (46%, 6/13) received baseline + step-up 1 + step-up 2, and 3 (23%, 3/13) received baseline + step-up 1 + step-up 2 +step-up 3. Data analysis is still ongoing through spring 2018. CONCLUSIONS: This is one of the first intervention studies to use an individually tailored, adaptive design to manage weight gain in pregnancy. Results from this study will be useful in designing a larger randomized trial to examine efficacy of this intervention and developing strategies for clinical application. REGISTERED REPORT IDENTIFIER: RR1-10.2196/9220.