Access, Interest, and Barriers to Incorporation of Birth Doula Care in the United States.

Doula care improves maternal care, yet barriers exist to incorporating doula care. The purpose of this study was to evaluate interest and barriers to doula care. Overall, 508 women, 26-35 years of age (54.5%), White/Caucasian (89.8%), and married (88.6%), completed this study. Most reported ≥1 previous birth (97.6%). Respondents would "feel comfortable" (73.2%) and "more confident" (54.9%) with doula care at birth, and 57.9% reported their provider would be supportive of doula care. Only 39.0% expressed benefits to doula care during pregnancy compared to 72.6% at birth and 68.1% during postpartum. Most would hire a doula if health insurance covered some of the costs. Despite the recognized benefits and support of doula care, cost-associated barriers exist to the incorporation of doula care.

No strong evidence of the protein leverage hypothesis in pregnant women with obesity and their infants.

OBJECTIVE: The goal of this study was to investigate the role of dietary protein on macronutrient and energy intake, maternal adiposity during pregnancy, and infant adiposity at birth. METHODS: In 41 women with obesity, early-pregnancy (13-16 weeks) protein intake was assessed with food photography and expressed as a ratio of Estimated Average Requirements (EAR) in pregnancy for protein (0.88 g/kg/d), herein "protein balance." Energy intake was measured by the intake-balance method, gestational weight gain as grams per week, and fat mass by a three-compartment model. Spearman correlations and linear models were computed using R version 4.1.1 (p < 0.05 considered significant). RESULTS: Women had a mean (SD) age of 27.5 (4.8) years and a pregravid BMI of 34.4 (2.9), kg/m2 , and the majority were non-White (n = 23, 56.1%). Protein balance in early pregnancy was not significantly associated with energy intake across mid and mid/late pregnancy (ß = 328.7, p = 0.30 and ß = 286.2, p = 0.26, respectively) or gestational weight gain (ß = 117.0, p = 0.41). Protein balance was inversely associated with fat mass in early, mid, and late pregnancy (ß = -10.6, p = 0.01, ß = -10.4, p = 0.03, ß = -10.3, p = 0.03, respectively). Protein balance did not predict infant adiposity at birth (p > 0.05). CONCLUSIONS: Low protein intake may have been present before pregnancy, explaining early relationships with adiposity in this cohort. The protein leverage hypothesis is likely not implicated in the intergenerational transmission of obesity.

Infant Feeding Varies Across Eating Behavior and Feeding Modalities in Mothers With Low Income.

OBJECTIVE: To examine if eating behaviors in mothers with low income relate to attitudes toward infant feeding and whether associations differed between breastfeeding and formula-feeding mothers. DESIGN: Cross-sectional study. PARTICIPANTS: Forty postpartum women (aged ≥ 18 years, body mass index ≥ 25 and &lt; 40 kg/m²) in the Louisiana Women, Infants, and Children program participated in a telehealth postpartum intervention for health and weight loss. MAIN OUTCOME MEASURE(S): Maternal eating behaviors and infant feeding styles, assessed 6-8 weeks after birth (baseline) using validated questionnaires. ANALYSIS: Significance was detected using independent t tests, chi-square tests for independence, or linear models (P &lt; 0.05). RESULTS: Most mothers formula-fed (n = 27, 68%). In formula-feeding mothers, maternal disinhibition and perceived hunger were positively associated with restrictive infant feeding (ß = 0.41, P &lt;0.001 and ß = 0.41, P = 0.001, respectively). These relationships were significantly higher (Δ = -0.85, P = 0.006 and Δ = -0.59, P = 0.003, respectively) than among breastfeeding mothers. Comparatively, pressuring/overfeeding was lower in formula-feeding mothers than among breastfeeding mothers with dietary restraint (Δ slopes: 1.06, P = 0.02). CONCLUSIONS AND IMPLICATIONS: In this cohort of mothers with low income, maternal eating behavior was associated with infant feeding styles only when feeding modality was considered. Mothers may benefit from education on how their eating behaviors can influence their infants and children.

Impact of COVID-19 Stay-at-Home Orders on Health Behaviors and Anxiety in Black and White Americans.

BACKGROUND: In the United States (US), the incidence and severity of COVID-19 infections, hospitalizations, and deaths are higher in Black compared to White residents. Systemic inequities and differences in health behaviors may contribute to disparities in COVID-19 health outcomes. The aim of this study was to examine the impact of COVID-19 stay-at-home orders on changes in health behaviors and anxiety in Black and White adults residing in the US. METHODS: Beginning April 2020, the Pennington Biomedical Research Center COVID-19 Health Behaviors Study collected information on changes to employment, income, diet, physical activity, anxiety, and sleep patterns through a global online survey. RESULTS: Of 4542 survey respondents in the US, 7% identified as Black and 93% as White. Prior to the COVID-19 stay-at-home orders, a greater proportion of Blacks compared to Whites reported earning < US$50,000 per year (p < 0.0001). A greater proportion of Blacks reported being laid off, working fewer hours, and working from home following COVID-19 stay-at-home orders (p < 0.0001 for all). In the overall sample, eating behaviors improved, physical activity decreased, sleep time prolonged, and anxiety heightened following COVID-19 stay-at-home orders (p < 0.01 for all), which were universal between Black and White respondents (p ≥ 0.315 for all). CONCLUSIONS: This study highlights the disproportionate changes to employment and income in Blacks, with no differential impact on health behaviors and anxiety compared to Whites due to COVID-19 stay-at-home orders. As the COVID-19 pandemic continues, disproportionate changes to employment and income status may widen among Blacks and Whites, which may influence health behaviors and anxiety.

A role for the early pregnancy maternal milieu in the intergenerational transmission of obesity.

OBJECTIVE: Maternal obesity increases the risks for adverse pregnancy and offspring outcomes but with large heterogeneity. This study examined changes to the maternal metabolic milieu across pregnancy in women with obesity. It identified differences between a metabolically unhealthy obesity (MUO) phenotype and a metabolically healthy obesity (MHO) phenotype, as well as the differences in offspring adiposity between the two metabolic phenotypes. METHODS: In early pregnancy, women were classified with MHO (n = 13) or MUO (n = 9) based on the presence of zero or ≥2 risk factors for metabolic syndrome, respectively (systolic blood pressure > 130 mm Hg or diastolic blood pressure > 85 mm Hg, HDL cholesterol < 50 mg/dL, LDL cholesterol ≥ 100 mg/dL, triglycerides ≥ 150 mg/dL, and glucose ≥ 100 mg/dL). Area under the pregnancy concentration curve for glucose and triglycerides measured at early (13-16 weeks), mid- (24-27 weeks), and late (35-37 weeks) pregnancy, gestational weight gain (GWG), energy expenditure, maternal fat accretion, and infant body composition were compared. RESULTS: Maternal BMI, GWG, and fat accretion did not differ between MUO and MHO. Women with MUO had a greater area under the pregnancy concentration curve for glucose (+2,170 [382] mg/dL·day, p < 0.001) and triglycerides (+12,211 [3,916] mg/dL·day, p < 0.001). There were no differences in late-pregnancy total daily energy expenditure, but activity energy expenditure was significantly lower in MUO (-403 [144] kcal). MUO offspring had greater weight (+621 [205] g, p = 0.01) and adiposity (+5.8% [2.1%], p = 0.02) at 1 week of life but showed no differences in fat-free mass. CONCLUSIONS: Independent of GWG, MUO resulted in heightened exposure of fetal fat-promoting substrates. Differing metabolic phenotypes may explain heterogeneity of offspring adiposity born to women with obesity.

Practical application of in vivo MRI-based brown adipose tissue measurements in infants.

OBJECTIVE: The role of brown adipose tissue (BAT) in infant metabolism remains poorly understood, primarily because of the inherent limitation of positron emission tomography/computed tomography imaging to measure BAT, which is not suitable for infants. The aims of this method development study were to assess the feasibility, intra-rater reliability, interscan repeatability, and physiological relevance of measuring BAT in infants using magnetic resonance imaging (MRI). METHODS: A total of 10 nonsedated infants (mean age, 22.6 [1.3] days old) completed two 3-T MRI exams using chemical-shift-encoded water-fat scans 6.2 (2.8) days apart. Candidate BAT voxels in the supraclavicular region were identified based on fat signal fraction (FSF). The volumes of BAT depots were manually traced, and FSF was calculated. Whole-body fat mass was determined using dual-energy x-ray absorptiometry. RESULTS: Images were successfully obtained from 19 of 20 (95%) attempted scans. The mean BAT volume was 5.41 (SD 1.1) cm3 , and the mean FSF was 16.41% (SD 3.3%). Intra-rater analysis showed good reliability with no systemic bias (proportional bias for volume: p = 0.19; FSF: p = 0.30). Test-retest for interscan repeatability was good (intraclass correlation coefficients for volume: 0.92, p = 0.001 and intraclass correlation coefficients for FSF: 0.93, p < 0.001). FSF was inversely related to fat-free mass (r = -0.69, p = 0.03). CONCLUSIONS: This method development study supports the use of MRI to obtain reliable and quantitative measurements of BAT volume in infants.

Factors Protecting against a Decline in Physical Activity during the COVID-19 Pandemic.

PURPOSE: The spread of COVID-19 and the associated stay-at-home orders and shutdowns of gyms and fitness centers have drastically influenced health behaviors leading to widespread reductions in physical activity (PA). The recent Call to Action from the American College of Sports Medicine has promoted "innovative strategies to promote PA during the COVID-19 pandemic." We aimed to identify individual-level factors that protected against declines in PA levels amid the COVID-19 restrictions. METHODS: We used the Pennington Biomedical COVID-19 Health Behaviors Survey for our analyses and used mixed-effect linear and generalized linear models to estimate the effects of individual-level factors on changes in PA levels during the COVID-19 restrictions. RESULTS: Participants (n = 4376) provided information on PA behaviors before and during the COVID-19 shutdown. Overall, PA levels declined by a mean ± SD of 112 ± 1460 MET·min·wk-1 during the COVID-19 shutdown; however, changes in PA were heterogeneous, with 55% of the participants reporting increases in or maintenance of PA during that time. Several social and demographic factors were significantly related to declines in PA, including high prepandemic PA levels, living alone (difference = 118 MET·min·wk-1), low household income (difference between the highest and the lowest income group = 363 MET·min·wk-1), COVID-19-related changes in income (difference = 110 MET·min·wk-1), and loss of employment (difference = 168 MET·min·wk-1). The substitution of prepandemic gym attendance with the purchase and use of home exercise equipment or exercise through virtual fitness platforms promoted increases in PA during the COVID-19 shutdown. CONCLUSIONS: While promoting PA through the COVID-19 pandemic, it is important to consider demographic factors, which greatly influence health behaviors and implementation of, and access to, replacement behaviors. The promotion of such strategies could help maintain PA levels during potential future stay-at-home orders.

Identification of changes in sleep across pregnancy and the impact on cardiometabolic health and energy intake in women with obesity.

This prospective, observational study investigated changes in sleep and the effect on energy intake, gestational weight gain, and cardiometabolic health across pregnancy in 52 healthy pregnant women with obesity. Habitual sleep was assessed by wrist-worn actigraphy (time spent in bed; TIB, total sleep time; TST, and sleep efficiency) in early (130-156 weeks) and late (350-366) pregnancy. A change to habitual sleep was defined as change of one-half of the standard deviation of TIB and TST across six consecutive nights from early pregnancy. Energy intake and changes in weight, fasting glucose, insulin, and lipids across pregnancy were compared between women who changed sleep. During early pregnancy, TIB was 9:24 ± 0:08 h and varied by 1:37 ± 0:07 h across the six nights. TST and sleep efficiency significantly declined from early to late pregnancy (7:03 ± 0:08 h to 6:28 ± 0:09 h, p < 0.001) and (76 ± 0.1% to 71 ± 0.2%, p < 0.001), respectively. For women who increased TIB (n = 11), fasting glucose decreased (-11.6 ± 4.3%, p < 0.01) across pregnancy and they had a trend towards decreased insulin (-57.8 ± 33.5%; p = 0.09) and HOMA-IR (-72.4 ± 37.3%; p = 0.06) compared to women who decreased TIB (n = 13). Women who increased TIB had a significantly lower daily energy intake across pregnancy (-540 ± 163 kcal; p < 0.01) and tended to have less gestational weight gain (-147 ± 88 g/week; p = 0.10). Changes in TST did not affect plasma markers, energy intake or weight gain. The positive relationship between sleep and cardiometabolic health during pregnancy is explained in part by lower energy intake. We hypothesize lower energy intake is due to a prolonged overnight fast and a decrease in the time available for eating.

The Impact of COVID-19 Stay-At-Home Orders on Health Behaviors in Adults.

OBJECTIVE: Stay-at-home orders in response to the coronavirus disease 2019 (COVID-19) pandemic have forced abrupt changes to daily routines. This study assessed lifestyle changes across different BMI classifications in response to the global pandemic. METHODS: The online survey targeting adults was distributed in April 2020 and collected information on dietary behaviors, physical activity, and mental health. All questions were presented as "before" and "since" the COVID-19 pandemic. RESULTS: In total, 7,753 participants were included; 32.2% of the sample were individuals with normal weight, 32.1% had overweight, and 34.0% had obesity. During the pandemic, overall scores for healthy eating increased (P < 0.001), owing to less eating out and increased cooking (P < 0.001). Sedentary leisure behaviors increased, while time spent in physical activity (absolute time and intensity adjusted) declined (P < 0.001). Anxiety scores increased 8.78 ± 0.21 during the pandemic, and the magnitude of increase was significantly greater in people with obesity (P ≤ 0.01). Weight gain was reported in 27.5% of the total sample compared with 33.4% in participants with obesity. CONCLUSIONS: The COVID-19 pandemic has produced significant health effects, well beyond the virus itself. Government mandates together with fear of contracting the virus have significantly impacted lifestyle behaviors alongside declines in mental health. These deleterious impacts have disproportionally affected individuals with obesity.

Maternal mindful eating as a target for improving metabolic outcomes in pregnant women with obesity.

BACKGROUND: Maternal diet and eating behaviors have the potential to influence the metabolic milieu in pregnancies complicated by obesity, with implications for the developmental programming of offspring obesity. Emerging evidence suggests that mindfulness during eating may influence metabolic health in non-pregnant populations, but its effects in the context of pregnancy is less well understood. This study explored the individual and combined effects of mindful eating and diet quality on metabolic outcomes among pregnant women with obesity. METHODS: In 46 pregnant women (body mas index >30 kg/m2) enrolled in the MomEE observational study, mindful eating (Mindful Eating Questionnaire, MEQ) and energy-adjusted dietary inflammatory index (DII, from 7 days of food photography) was assessed at two time points and the mean pregnancy values computed. Rate of gestational weight gain (GWG) and fat mass gain per week were determined from measured weight and body composition using a three-compartment method, respectively, at each assessment. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and ghrelin concentrations were determined from fasting blood samples in late gestation (35-37 weeks). Linear regression was used to examine the association of the MEQ and its subscales (where higher values indicate more mindful eating) with metabolic outcomes, adjusting for covariates: maternal age, pregravid body mass index, race, parity, DII. The effects of the MEQ*DII interaction was also tested. RESULTS: Total MEQ scores were not associated with rate of weight or fat mass gain, although greater distracted eating behavior was associated with greater adiposity gain (weight and fat mass). Mindful eating was inversely associated with insulin resistance, although this was attenuated to non-significance after additional adjustment for GWG. Total MEQ and the external eating subscale was significantly inversely associated with fasted ghrelin, such that less tendency to eat under the influence of external cues was associated with lower ghrelin concentrations. After false discovery rate adjustment for multiple testing, only the association of the total MEQ and external eating subscale with ghrelin levels trended towards significance. The DII was not associated with MEQ scores or outcome variables, nor did it moderate the effect of MEQ on any of the outcomes. CONCLUSION: This study generates early evidence to suggest that mindful eating holds potential as a tool to improve metabolic health outcomes in pregnant women with obesity, although further research is required on this topic. Prenatal lifestyle interventions should consider including mindfulness during eating to determine its efficacy for reducing adverse pregnancy and offspring health outcomes associated with maternal obesity.

Discrimination of wear and non-wear in infants using data from hip- and ankle-worn devices.

INTRODUCTION: A key component to analyzing wearable sensor data is identifying periods of non-wear. Traditionally, strings of consecutive zero counts (e.g. >60-minutes) are identified indicating periods of non-movement. The non-movement window length is then evaluated as wear or non-wear. Given that non-movement is not equivalent to non-wear, additional criteria should be evaluated to objectively identify periods of non-wear. Identifying non-wear is especially challenging in infants due to their sporadic movement, sleep frequency, and proportion of caregiver-generated movement. PURPOSE: To use hip- and ankle-worn ActiGraph wGT3X-BT (wGT3X-BT) data to identify non-wear in infants. METHODS: Fifteen infant participants [mean±SD; age, 8.7±1.7 weeks (range 5.4-11.3 weeks); 5.1±0.8 kg; 56.2±2.1 cm; n = 8 females] wore a wGT3X-BT on the hip and ankle. Criterion data were collected during two, 2-hour directly observed periods in the laboratory. Using raw 30 Hz acceleration data, a vector magnitude and the inclination angle of each individual axis were calculated before being averaged into 1-minute windows. Three decision tree models were developed using data from 1) hip only, 2) ankle only, and 3) hip and ankle combined. RESULTS: The hip model classified 86.6% of all minutes (wear and non-wear) correctly (F1 = 75.5%) compared to the ankle model which classified 90.6% of all minutes correctly (F1 = 83.0%). The combined site model performed similarly to the ankle model and correctly classified 90.0% of all minutes (F1 = 80.8%). CONCLUSION: The similar performance between the ankle only model and the combined site model likely indicates that the features from the ankle device are more important for identifying non-wear in infants. Overall, this approach provides an advancement in the identification of device wear status using wearable sensor data in infants.

The Design of a Randomized Clinical Trial to Evaluate a Pragmatic and Scalable eHealth Intervention for the Management of Gestational Weight Gain in Low-Income Women: Protocol for the SmartMoms in WIC Trial.

BACKGROUND: Less than one-third of women gain an appropriate amount of weight during pregnancy, which can influence the long-term health of both the mother and the child. Economically disadvantaged women are the most vulnerable to maternal obesity, excessive weight gain during pregnancy, and poor birth outcomes. Effective and scalable health care strategies to promote healthy weight gain during pregnancy specifically tailored for these women are lacking. OBJECTIVE: This paper presents the design and protocol of a biphasic, community-based eHealth trial, SmartMoms in WIC, to increase the adherence to healthy gestational weight gain (GWG) recommendations in low-income mothers receiving women, infant, and children (WIC) benefits. METHODS: Phase 1 of the trial included using feedback from WIC mothers and staff and participants from 2 community peer advisory groups to adapt an existing eHealth gestational weight management intervention to meet the needs of women receiving WIC benefits. The health curriculum, the format of delivery, and incentive strategies were adapted to be culturally relevant and at an appropriate level of health literacy. Phase 2 included a pragmatic randomized controlled trial across the 9 health care regions in Louisiana with the goal of enrolling 432 women. The SmartMoms in WIC intervention is an intensive 24-week behavioral intervention, which includes nutrition education and exercise strategies, and provides the technology to assist with weight management, delivered through a professionally produced website application. RESULTS: Phase 1 of this trial was completed in July 2019, and recruitment for phase 2 began immediately thereafter. All data are anticipated to be collected by Spring 2023. CONCLUSIONS: The SmartMoms in WIC curriculum was methodically developed using feedback from community-based peer advisory groups to create a culturally relevant, mobile behavioral intervention for mothers receiving WIC benefits. The randomized clinical trial is underway to test the effectiveness of a sustainable eHealth program on the incidence rates of appropriate GWG. SmartMoms in WIC may be able to offer an innovative, cost-effective, and scalable solution for GWG management in women served by WIC. TRIAL REGISTRATION: ClinicalTrials.gov NCT04028843; https://clinicaltrials.gov/ct2/show/NCT04028843. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18211.

Modifications to Infant Formula Instructions Improve the Accuracy of Formula Dispensing.

Readability of infant formula preparation instructions is universally poor, which may result in inaccurate infant feeding. Given that inaccurate formula dispensing can lead to altered infant growth and increased adiposity, there is an increased need for easy to follow instructions for formula preparation. We hypothesize that altering infant formula instruction labels using feedback from iterative focus groups will improve the preparation accuracy of powdered infant formula in a randomized controlled trial. Participants were recruited from the community, 18 years of age or older, willing to disclose demographic information for focus group matching, and willing to participate freely in the first (n = 21) or second (n = 150) phase of the study. In the second phase, participants were randomized to use the standard manufacturer instructions or to use the modified instructions created in the first phase. Accuracy was defined as the percent error between manufacturer-intended powder formula quantity and the amount dispensed by the participant. Participants who were assigned to the modified instructions were able to dispense the powdered formula more accurately than participants who used the standard manufacturer instructions (-0.67 ± 0.76 vs. -4.66 ± 0.74% error; p < 0.0001). Accuracy in powdered formula dispensing was influenced by bottle size (p = 0.02) but not by body mass index (p = 0.17), education level (p = 0.75), income (p = 0.7), age (p = 0.89) or caregiver status (p = 0.18). Percent error of water measurement was not different between the groups (standard: -1.4 ± 0.6 vs. modified: 0.7 ± 0.6%; p = 0.38). Thus, caloric density was more accurate in the modified instructions group compared to the standard manufacturer instructions group (-0.3 ± 0.6 vs.-2.9 ± 0.9%; p = 0.03). Infant formula label modifications using focus group feedback increased infant formula preparation accuracy.

Increased Energy Intake After Pregnancy Determines Postpartum Weight Retention in Women With Obesity.

CONTEXT: This study was designed to understand causes and critical periods for postpartum weight retention by characterizing changes in body composition, energy intake, energy expenditure and physical activity in women with obesity during pregnancy and postpartum. DESIGN: In this prospective, observational cohort study, body composition (plethysmography), energy expenditure (doubly labeled water, whole-body room calorimetry), physical activity (accelerometry), metabolic biomarkers, and eating behaviors were measured. Energy intake was calculated by the intake-balance method for pregnancy, and for 2 postpartum periods (0 to 6 months and 6 to 12 months). RESULTS: During the 18-month observation period, weight loss occurred in 16 (43%) women (mean ± SEM, -4.9 ± 1.6 kg) and weight retention occurred in 21 (57%) women (+8.6 ± 1.4 kg). Comparing women with postpartum weight loss and weight retention, changes in body weight were not different during pregnancy (6.9 ± 1.0 vs 9.5 ± 0.9 kg, P = 0.06). After pregnancy, women with postpartum weight loss lost -3.6 ± 1.8 kg fat mass whereas women with weight retention gained 6.2 ± 1.7 kg fat mass (P < 0.001). Women with postpartum weight loss reduced energy intake during the postpartum period (compared with during pregnancy) by 300 kcal/d (1255 kJ/d), while women with weight retention increased energy intake by 250 kcal/d (1046 kJ/d, P < 0.005). There were no differences in the duration of breastfeeding, eating behavior, or metabolic biomarkers. CONCLUSIONS: Postpartum weight gain was the result of increased energy intake after pregnancy rather than decreased energy expenditure. Dietary intake recommendations are needed for women with obesity during the postpartum period, and women should be educated on the risk of overeating after pregnancy.

Body Composition During Pregnancy Differs by Obesity Class.

OBJECTIVE: The aim of this study is to characterize changes in body composition during pregnancy in women with obesity. METHODS: Fifty-four healthy women with obesity (class 1, 30-34.9 kg/m2 : n = 25; class 2, 35-39.9 kg/m2 : n = 21; class 3, ≥ 40.0 kg/m2 : n = 8) expecting a singleton pregnancy were studied. Body composition was measured in early pregnancy (13-16 weeks), midpregnancy (24-27 weeks), and late pregnancy (35-37 weeks) using air displacement plethysmography, stable isotopes, and skinfold thickness measurements. Fasting glucose, insulin, and leptin were measured. RESULTS: The gain in fat-free mass was lower in the second trimester compared with the third (2.7 ± 0.2 to 5.3 ± 0.2 kg; P < 0.001), whereas fat mass accumulation declined over time (0.6 ± 0.3 to -0.7 ± 0.4 kg; P = 0.005). Women with class 1 and 2 obesity gained 1.1 ± 0.7 kg of fat mass during pregnancy, while women with class 3 obesity lost 4.1 ± 0.6 kg (both P < 0.001). The difference in fat accumulation between obesity classes was observed only in the second trimester (P = 0.02). Gestational weight gain was associated positively with changes in plasma concentrations of insulin, leptin, and insulin resistance (all P < 0.01). CONCLUSIONS: Gestational weight gain in pregnancy differs by obesity class and trimester. Women with class 3 obesity gain less body weight and fat mass. Fat mass gain is most likely preventable in the second trimester.

Evidence-based recommendations for energy intake in pregnant women with obesity.

BACKGROUND: In women with obesity, excess gestational weight gain (≥270 g/week) occurs in two out of three pregnancies and contributes to metabolic impairments in both mother and baby. To improve obstetrical care, objectively assessed information on energy balance is urgently needed. The objective of this study was to characterize determinants of gestational weight gain in women with obesity. METHODS: This was a prospective, observational study of pregnant women with obesity. The primary outcome was energy intake calculated by the energy intake-balance method. Energy expenditure was measured by doubly-labeled water and whole-room indirect calorimetry and body composition as 3-compartment model by air displacement plethysmography and isotope dilution in early (13-16 weeks) and late pregnancy (35-37 weeks). RESULTS: In pregnant women with obesity (n=54), recommended weight gain (n=8, 15%) during the second and third trimesters was achieved when energy intake was 125±52 kcal/d less than energy expenditure. In contrast, women with excess weight gain (67%) consumed 186±29 kcal/d more than they expended (P<0.001). Energy balance affected maternal adiposity (recommended: -2.5±0.8 kg fat mass, excess: +2.2±0.5, inadequate: -4.5±0.5, P<0.001), but not fetal growth. Weight gain was not related to demographics, activity, metabolic biomarkers, or diet quality. We estimated that energy intake requirements for recommended weight gain during the second and third trimesters were not increased as compared to energy requirements early in pregnancy (34±53 kcal/d, P=0.83). CONCLUSIONS: We here provide the first evidence-based recommendations for energy intake in pregnant women with obesity. Contrary to current recommendations, energy intake should not exceed energy expenditure. FUNDING: This study was funded by the National Institutes of Health (R01DK099175; Redman, U54GM104940 and P30DK072476; Core support). TRIAL REGISTRATION: clinicaltrials.gov: NCT01954342.

Unintentional error in formula preparation and its simulated impact on infant weight and adiposity.

BACKGROUND: Accelerated weight gain in infancy is a public health issue and is likely due to feeding behaviours. OBJECTIVES: To test the accuracy of individuals to dispense infant formula as compared with recommended serving sizes and to estimate the effect of dispensing inaccuracy on infant growth. METHODS: Fifty-three adults dispensed infant formula powder for three servings of 2, 4, 6, and 8 fl oz bottles, in random order. The weight of dispensed infant formula powder was compared with the recommended serving size weight on the nutrition label. A novel mathematical model was used to estimate the impact of formula dispensing on infant weight and adiposity. RESULTS: Nineteen percent of bottles (20 of 636) prepared contained the recommended amount of infant formula powder. Three percent were underdispensed, and 78% of bottles were overdispensed, resulting in 11% additional infant formula powder. Mathematical modelling feeding 11% above energy requirements exclusively for 6 months for male and female infants suggested infants at the 50th percentile for weight at birth would reach the 75th percentile with increased adiposity by 6 months. CONCLUSIONS: Inaccurate measurement of infant formula powder and overdispensing, which is highly prevalent, specifically, may contribute to rapid weight gain and increased adiposity in formula-fed infants.

Behavioral Determinants of Objectively Assessed Diet Quality in Obese Pregnancy.

Interventions to promote healthy pregnancy in women with obesity by improving diet quality have been widely unsuccessful. We hypothesized that diet quality is determined by eating behaviors, but evidence in women with obesity is lacking. We evaluated diet quality and eating behavior in 56 women with obesity (mean ± SEM, 36.7 ± 0.7 kg/m2, 46% White, 50% nulliparous) early in pregnancy (14.9 ± 0.1 weeks). Diet quality was objectively assessed with food photography over six days and defined by Healthy Eating Index. Eating behaviors were assessed by validated questionnaires. Women reported consuming diets high in fat (38 ± 1% of energy) and the HEI was considered "poor" on average (46.7 ± 1.3), and for 71% of women. Diet quality was independently associated with education level (p = 0.01), food cravings (p < 0.01), and awareness towards eating (p = 0.01). Cravings for sweets and fast foods were positively correlated with respective intakes of these foods (p < 0.01 and p = 0.04, respectively), whereas cravings for fruits and vegetables did not relate to diet intake. We provide evidence of the determinants of poor diet quality in pregnant women with obesity. Based on this observational study, strategies to improve diet quality and pregnancy outcomes are to satisfy cravings for healthy snacks and foods, and to promote awareness towards eating behaviors.

Mood and quality of life changes in pregnancy and postpartum and the effect of a behavioral intervention targeting excess gestational weight gain in women with overweight and obesity: a parallel-arm randomized controlled pilot trial.

BACKGROUND: Intensive lifestyle interventions in pregnancy have shown success in limiting gestational weight gain, but the effects on mood and quality of life in pregnancy and postpartum are less known. The purpose was to quantify changes in mental and physical quality of life and depressive symptoms across pregnancy and the postpartum period, to determine the association between gestational weight gain and change in mood and quality of life, and to assess the effect of a behavioral intervention targeting excess gestational weight gain on these outcomes. METHODS: A three group parallel-arm randomized controlled pilot trial of 54 pregnant women who were overweight or obese was conducted to test whether the SmartMoms® intervention decreased the proportion of women with excess gestational weight gain. Individuals randomized to Usual Care (n = 17) did not receive any weight management services from interventionists. Individuals randomized to the SmartMoms® intervention (n = 37) were provided with behavioral weight management counseling by interventionists either in clinic (In-Person, n = 18) or remotely through a smartphone application (Phone, n = 19). In a subset of 43 women, mood and mental and physical quality of life were assessed with the Beck Depression Inventory-II and the Rand 12-Item short form, respectively, in early pregnancy, late pregnancy, 1-2 months postpartum, and 12 months postpartum. RESULTS: The SmartMoms® intervention and Usual Care groups had higher depressive symptoms (p < 0.03 for SmartMoms® intervention, p < 0.01 for Usual Care) and decreased physical health (p < 0.01) from early to late pregnancy. Both groups returned to early pregnancy mood and physical quality of life postpartum. Mental health did not change from early to late pregnancy (p = 0.8), from early pregnancy to 1-2 months (p = 0.5), or from early pregnancy to 12 months postpartum (p = 0.9), respectively. There were no significant intervention effects. Higher gestational weight gain was associated with worsened mood and lower physical quality of life across pregnancy. CONCLUSION: High depressive symptoms and poor quality of life may be interrelated with the incidence of excess gestational weight gain. The behavioral gestational weight gain intervention did not significantly impact these outcomes, but mood and quality of life should be considered within future interventions and clinical practice to effectively limit excess gestational weight gain. TRIAL REGISTRATION: NCT01610752 , Expecting Success, Registered 31 May 2012.