Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study.

PURPOSE: Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters. DESIGN: Observational cohort study. SUBJECTS AND SETTING: The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children. METHOD: Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters. RESULTS: Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only. CONCLUSIONS: Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

Perception and Comfort with Endometriosis Management Among OB/GYN Residents.

Purpose: The diagnosis of endometriosis often takes several years, delaying appropriate care while patients suffer from pelvic pain, dysmenorrhea, and dyspareunia. Understanding whether residents in obstetrics and gynecology (OB/GYN) are being adequately exposed to and trained in the diagnosis and management of the disease is important for improving care. Methods: We conducted an online cross-sectional survey of OB/GYN residents to investigate their comfort level and familiarity with endometriosis diagnosis and management. Residency program directors and coordinators of 20 OB/GYN residency programs in California, USA were emailed to disseminate the 31-question, anonymous survey in January to February 2023. Responses were collected using Redcap and analysis was conducted using STATA. Results: 67 residents answered at least one non-demographic question and were included. A resident response rate was not calculated because we were unable to determine how many programs distributed the survey. 84% of residents felt they could recognise symptoms of endometriosis but over 30% of senior residents were not comfortable with sonographic diagnosis of endometrioma. Approximately one third of residents felt comfortable managing hypoestrogenic symptoms, osteoporotic risks, and add-back progestin for certain hormonal therapies. Academic-hospital based residents had significantly more exposure to attendings prescribing long-acting reversible contraception, GnRH antagonists, and GnRH agonists but there were no significant differences in trainee prescribing practices or comfort. More respondents would feel comfortable medically managing endometriosis (52%) than surgically managing the disease (26%) if they were in practice today, with only 39% of PGY3-4 residents feeling comfortable surgically managing endometriosis. Conclusion: There is considerable room for improvement in the education of residents in the diagnosis and medical and surgical management of endometriosis.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data.

PURPOSE: We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women. METHODS: We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates. RESULTS: Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17. DISCUSSION: We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Associations Between Preconception Glycemia and Preterm Birth: The Potential Role of Health Care Access and Utilization.

Background: Preconception diabetes is strongly associated with adverse birth outcomes. Less is known about the effects of elevated glycemia at levels below clinical cutoffs for diabetes. In this study, we estimated associations between preconception diabetes, prediabetes, and hemoglobin A1c (HbA1c) on the risk of preterm birth, and evaluated whether associations were modified by access to or utilization of health care services. Materials and Methods: We used data from Add Health, a US prospective cohort study with five study waves to date. At Wave IV (ages 24-32), glucose and HbA1c were measured. At Wave V (ages 32-42), women with a live birth reported whether the baby was born preterm. The analytic sample size was 1989. Results: The prevalence of preterm birth was 13%. Before pregnancy, 6.9% of women had diabetes, 23.7% had prediabetes, and 69.4% were normoglycemic. Compared to the normoglycemic group, women with diabetes had 2.1 (confidence interval [95% CI]: 1.5-2.9) times the risk of preterm birth, while women with prediabetes had 1.3 (95% CI: 1.0, 1.7) times the risk of preterm birth. There was a nonlinear relationship between HbA1c and preterm birth such that risk of preterm birth emerged after HbA1c = 5.7%, a standard cutoff for prediabetes. The excess risks of preterm birth associated with elevated HbA1c were four to five times larger among women who reported unstable health care coverage and among women who used the emergency room as usual source of care. Conclusion: Our findings replicate prior research showing strong associations between preconception diabetes and preterm birth, adding that prediabetes is also associated with higher risk. Policies and interventions to enhance access and utilization of health care among women before pregnancy should be examined.

Toileting Behaviors and Lower Urinary Tract Symptoms: A Cross-sectional Study of Diverse Women in the United States.

Background: Toileting behaviors are increasingly recognized as factors potentially contributing to development of lower urinary tract symptoms (LUTS). Objectives: To examine adult women's toileting behaviors and LUTS across age and race/ethnicity groups and relationships between toileting behaviors and LUTS. Design: Planned secondary analysis of questionnaire data collected in a focus group study on bladder health. Settings: Questionnaires were completed at the conclusion of focus groups conducted in community settings affiliated with seven research centers across the United States. Participants: Community-living women regardless of LUTS status. Methods: Forty-four focus groups were conducted with 360 adolescent and adult cisgender women. After each focus group, participants completed questionnaires to assess toileting behaviors (Toileting Behaviors-Women's Elimination Behaviors Scale (TB-WEB)) and their experience of LUTS (Lower Urinary Tract Symptom Tool), This analysis includes quantitative data from the subgroup of 316 participants who completed the questionnaires. Results: Participants ranged in age from 18-93 years (Mean=50.2 years). A significant effect for age was found for delayed voiding behavior, reported by 76.5% of women ages 18-25 years and 21.9% of those 75+ years (p<0.001). Conversely, reports of premature voiding were lowest in the youngest and higher in the oldest three age groups (p=0.022). Racial/ethnic differences were found for three domains of toileting behavior. Black and Hispanic women expressed a stronger preference for voiding at home rather than away from home (98.9%, 93.5%, respectively) compared to White women (90.4%, p=0.041), were more likely to void prematurely (37.6%, 33.3% vs. 21.2%, p=0.048) and to crouch, squat, or stand rather than sit to void when away from home (69.9%, 58.3% vs. 41.3%, p<0.001). Four toileting behavior domains were significantly associated with LUTS. Premature voiding was associated with any bothersome LUTS (OR=2.5; 95% confidence interval [CI]=1.3-4.8) and any bothersome storage LUTS (OR=2.9; CI=1.5-5.5). Delayed voiding was associated with bothersome emptying symptoms (OR=2.8; CI=1.1-6.6). Straining to void was associated with bothersome storage symptoms (OR=2.0; CI=1.0-3.7), bothersome emptying symptoms (OR=3.7; CI=1.9-7.3), and any bothersome LUTS (OR=2.3; CI=1.2-4.3). Preference for non-sitting positions to void when away from home was associated with bothersome emptying symptoms (OR=2.5; CI=1.3-4.8) and any bothersome LUTS (OR=1.8; CI=1.0-3.2). Conclusions: These findings highlight the need for research to understand underpinnings of age and racial/ethnic differences in toileting behaviors and identify mechanisms by which toileting behaviors might influence development of LUTS over time. Understanding causal pathways is important in the development of public health interventions to encourage toileting behaviors that support bladder health.

Views of Normal Bladder Function Among Women Experiencing Lower Urinary Tract Symptoms.

OBJECTIVE: To explore the perspectives of normal bladder function among women with lower urinary tract symptoms. METHODS: This was a secondary analysis of qualitative data from structured interviews with 50 adult women with lower urinary tract symptoms. A directed content analysis of the transcripts explored women's perspectives on normal bladder function. RESULTS: Participants' descriptions of "normal" took many forms and were based on several aspects of bladder function. A prominent feature of normal was that voiding occurred as a seamless process, beginning with an urge sensation, followed by voiding with ease and to completion, and then "being done." Descriptions of normal were based largely on concepts of voiding regularity, including voiding frequency, intervals, and patterns during the day and night. Another aspect of normal bladder function was the notion of having control in terms of not leaking urine, as well as the ability to hold urine and defer urination. Views of normal bladder function extended to the absence of symptoms and the impact of being symptom-free on day-to-day life, including not having to think about or worry about the bladder or limit daily activities. CONCLUSION: Women's perspectives on normal bladder function are multifaceted, reflecting attributes most salient to each individual and likely informed by their personal experience with symptoms and their influence on daily life. This work has implications for how clinicians might engage women in discussing bladder symptoms and can inform future research and public health messaging about normal bladder function.

Contributions, Aspirations, and Challenges of Academic Specialist Divisions in Obstetrics and Gynecology.

Shortly after its inception, the Society for Academic Specialists in General Obstetrics and Gynecology recognized that no data described the composition and faculty activities of "academic generalist divisions." Consequently, in 2018, the Society for Academic Specialists in General Obstetrics and Gynecology appointed a presidential task force and conducted the current surveys of chairs and division directors and key informant interviews to understand the composition and faculty activities in divisions of academic specialists in departments of obstetrics and gynecology and propose criteria for excellence in each mission area to guide development of divisions. In 2014, with Society for Academic Specialists in General Obstetrics and Gynecology's guidance, these divisions were referred to as academic specialists divisions and the faculty within as academic specialists to emphasize that they provide specialized women's health care in academic settings. The divisions comprised approximately 30% of departments' full-time faculty (median 12). In 27% of the departments, these divisions contributed more than half of departmental revenue, and 49% contributed 26-50%. Nearly 90% of divisions provided a sizeable proportion of the department's total teaching efforts. Compensation relied more on clinical productivity than on seniority, quality, academic contributions, or academic rank. Subsequently, five performance domains were identified to help divisions define divisional excellence: clinical, education, research, service & advocacy, and academic environment. Furthermore, excellent divisions were characterized as those with outstanding clinicians and educators who emphasize scholarly productivity. Although academic specialists contribute significantly to their departments' financial, clinical, and educational productivity, many have limited opportunities for scholarly activity. Achieving divisional excellence likely will depend on the ability to recruit and retain faculty with career expectations that align with the division's prioritized performance domains.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women.

AIMS: Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS: Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS: Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS: This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

Positive antenatal Edinburgh Depression Scale: examining behavioral and pharmacological therapy on maternal and neonatal outcomes.

Objective: We hypothesized that women with a positive antenatal Edinburgh Depression Screen (EPDS) (≥10), undergoing behavioral or pharmacologic therapy have improved maternal and neonatal outcomes.Study design: This is a retrospective study of singleton pregnancies at UC, San Diego from 2010 to 2014. Patients with an antenatal EPDS were subdivided based on their intervention: negative score, positive score no treatment, behavioral therapy only, and pharmacologic therapy. The primary outcome was rate of preterm birth with secondary outcomes of maternal and neonatal outcomes.Results: Patients with a positive EPDS had a higher rate of preterm delivery, small-for-gestational age, NICU admission and Apgar score <7. Rates of adverse outcomes were highest among women receiving pharmacologic therapy. Rates of adverse outcomes women were not increased in the behavioral therapy group compared to the negative EPDS group. When adjusting for confounding variables, patient with a positive EPDS were more likely deliver preterm with an adjusted odds ratio of 1.71. Among varying treatment modalities, the odds ratio for preterm delivery was not statistically significant.Conclusion: Adverse pregnancy outcomes were highest among those requiring pharmacotherapy. Behavioral therapy had a positive effect on outcomes. Intervention to reduce these adverse outcomes in these patients needs further study.

A Feasibility Study to Promote Optimal Weight in First Time Pregnant Mothers and Their Babies: Lessons Learned in a US-Mexico Border Community.

Introduction Obesity rates among US Hispanic women and children are high. Childhood obesity prevention beginning prenatally is desirable, but studies show mixed results. Methods We tested a pilot intervention to promote optimal gestational and infant weight with primigravid Hispanic women at a Federally Qualified Health Center (FQHC) on the U.S.-Mexico border. The intervention included promotora-led exercise, nutrition, breastfeeding activities (n = 23), supported by text/social media messaging (text messaging prenatally, private Facebook page postnatally). Measures included demographics, BMI, weight gain/retention, infant feeding, and attendance. Results Most women were U.S. born (73%), Spanish-language dominant (83%), with ≤ high school education (65%), and overweight/obese (56%). Retention rates were modest for the prenatal component (50%), supported by an SMS text-messaging program. Retention of the remaining postnatal sample, supported by a private Facebook® page, was 100%. Of women who regularly attended group sessions pre and postpartum, over 70% were within 5 lbs of pre-pregnancy weight at 6 months postpartum. A private Facebook® group was feasible for out-of-class support, including among women with regular cross-border mobility. Discussion While the intervention was well-received, almost 2/3 of the original participants did not follow up postpartum. Importantly, the findings indicate the use of social media (private Facebook® page) was more feasible than the SMS text-messaging program and may be a successful approach to reach and engage women living in mobile and transnational settings. Future studies should examine social media as an intervention tool to influence optimal weight and encourage healthy behaviors in primigravidas living near the U.S.-Mexico border.

Wearable Fetal Monitoring Solution for Improved Mobility During Labor & Delivery.

Electronic fetal monitoring (EFM) is used widely during labor & delivery, but existing solutions limit patient mobility, are uncomfortable, and do not consistently capture fetal heart rate (FHR) and uterine activity (UA) signals. A wireless EFM system was developed that features wearable US and tocodynamometer devices that conform to the body and do not require cables or belts. Benchtop testing demonstrated that the devices can accurately and consistently measure simulated FHRs and UAs over clinically meaningful ranges and body curvatures. The wearable EFM devices are expected to provide more reliable signal capture independent of maternal movement and repositioning, while also significantly improving patient comfort and mobility.

Incidence of wound complications after cesarean delivery: is suture closure better?

BACKGROUND: Wound complications (WC) following cesarean delivery (CD) result in significant morbidity. A randomized trial in 2013, which demonstrated lower WC rates with suture closure compared to staple closure, resulted in a practice change within our academic institution. OBJECTIVE: To determine the impact of this practice change on WC rates and identify other modifiable risk factors for WC. STUDY DESIGN: This is a retrospective cohort study of all women undergoing CD at the University of California, San Diego between 1 March 2011 and 28 February 2012 (primarily staple) and 1 March 2013 and 28 February 2014 (primarily suture). WC rates were compared between the two time intervals using Chi-square and Student's t-tests. Risk factors (OR, 95%CI) for WC were assessed using multiple logistic regression modeling. RESULTS: Of 1580 women delivered by CD, rates of WC were higher with staple closure compared to sutures (10.1% versus 4.5%; OR 2.4, 1.4-4.1). Additionally, WC were more likely with vertical skin incisions (OR 3.6, 1.6-8.1), CD for failed labor (OR 2.9, 1.1-7.4) and diabetes (OR 2.1, 1.4-3.9). CONCLUSIONS: After adjusting for confounders, there were over twofold increased odds of WC with staple closure. Vertical incisions, failed labor and diabetes also contributed to WC. Suture closure appears to decrease the risks of WC post CD.

Maternal obesity and sex-specific differences in placental pathology.

OBJECTIVE: Adverse effects of obesity have been linked to inflammation in various tissues, but studies on placental inflammation and obesity have demonstrated conflicting findings. We sought to investigate the influence of pregravid obesity and fetal sex on placental histopathology while controlling for diabetes and hypertension. METHODS: Placental histopathology focusing on inflammatory markers of a cohort of normal weight (BMI = 20-24.9) and obese (BMI ≥ 30) patients was characterized. Demographic, obstetric and neonatal variables were assessed. RESULTS: 192 normal and 231 obese women were included. Placental characteristics associated with obesity and fetal sex independent of diabetes and hypertension were placental disc weight >90(th) percentile, decreased placental efficiency, chronic villitis (CV), fetal thrombosis, and normoblastemia. Additionally, female fetuses of obese mothers had higher rates of CV and fetal thrombosis. Increasing BMI increased the risk of normoblastemia and CV. The final grade and extent of CV was significantly associated with obesity and BMI, but not fetal gender. Finally, CV was less common in large-for-gestation placentas. CONCLUSIONS: Maternal obesity results in placental overgrowth and fetal hypoxia as manifested by normoblastemia; it is also associated with an increased incidence of CV and fetal thrombosis, both more prevalent in female placentas. We have shown for the first time that the effect of maternal obesity on placental inflammation is independent of diabetes and hypertension, but significantly affected by fetal sex. Our data also point to the intriguing possibility that CV serves to normalize placental size, and potentially fetal growth, in the setting of maternal obesity.

Preconception Care of the Obese Woman.

One third of obese women report obtaining preconception care. Only one third of those women state that weight issues were discussed at their visit. Obese women should be educated about the risks of pregnancy so they can make informed choices as to whether and when to conceive. Women should be encouraged to mitigate risk by losing weight and exercising before conception and understand complications of pregnancy within specific pregravid body mass index strata. This manuscript describes the risks and provides guidance on topics to include in the preconception visit of an obese woman.

Early Second Trimester Weight Gain in Obese Women Predicts Excessive Gestational Weight Gain in Pregnancy.

OBJECTIVE: To assess gestational weight gain (GWG) in obese women to determine an inflection point that identifies women at risk for excessive weight gain. STUDY DESIGN: This is an observational prospective cohort study of pregnancies managed through the UC San Diego Maternal Weight and Wellness Program from 2011 to 2014. The primary outcome was total gestational weight gain. GWG was categorized as inadequate (<11 pounds), adequate (11-20 pounds), and excessive (>20 pounds) based on Institute of Medicine (IOM) recommendations. Other outcomes were GWG by trimester and postpartum weight retention. Bivariate and multivariate analyses were used to assess factors associated with GWG. RESULTS: Ninety-five patients had a mean prepregnancy body mass index (BMI) of 41.9 ± 8.9 kg/m(2) and a net weight gain of 21.9 ± 19 pounds. First trimester GWG was -0.3 ± 4.9 pounds, second trimester was 10.4 ± 10.8 pounds, and third trimester was 11.4 ± 8.5 pounds for all participants. Women who exceeded IOM recommendations accelerated weight gain at 12-14 weeks and gained a majority of weight during the second trimester. Weight gain of more than two pounds at 12-14 weeks had a 96 % positive predictive value (95 % CI 79-99) for excessive GWG. Postpartum women with excessive GWG retained more weight than those with inadequate GWG (10.7 ± 15.6 pounds compared with -13.6 ± 10.9 pounds, P < 0.001). On multiple linear regression GWG by trimester was predictive of total GWG with second and third trimester GWG having the greatest effect on total GWG. Prepregnancy BMI and gestational diabetes were not predictors of total GWG. CONCLUSIONS: Obese women at risk for excessive GWG may be identified as early as 12-14 weeks and gain most weight during the second trimester. GWG less than 11 pounds resulted in significant postpartum weight loss among obese women.

Enoxaparin dosing after cesarean delivery in morbidly obese women.

OBJECTIVE: To compare the adequacy of venous thromboembolism prophylaxis based on anti-Xa concentrations between weight-based enoxaparin dosing and body mass index (BMI)-stratified dosing in morbidly obese women after cesarean delivery. METHODS: A prospective sequential cohort study of women with BMIs of 40 or greater who underwent cesarean delivery was conducted. Participants received either weight-based or BMI-stratified enoxaparin dosing to prevent venous thromboembolism formation. The weight-based regimen was 0.5 mg/kg of enoxaparin every 12 hours. In the BMI-stratified regimen, women with BMIs of 40-59.9 received 40 mg enoxaparin every 12 hours and women with BMIs of 60 or greater received 60 mg every 12 hours. The primary outcome was an anti-Xa concentration in the adequate thromboprophylaxis range (0.2-0.6 international units/mL). Secondary outcomes included enoxaparin dosage, timing of dosing and anti-Xa concentration, estimated surgical blood loss, postoperative changes in hemoglobin and platelets, wound hematoma, and adverse reactions to enoxaparin. Univariate analysis was used to compare dosing regimens. RESULTS: Forty-two morbidly obese women received weight-based enoxaparin, and 43 received BMI-stratified dosing. Anti-Xa concentrations were significantly higher in the weight-based group compared with the BMI-stratified group (0.29±0.08 international units/mL compared with 0.17±0.07 international units/mL, P<.001). Thirty-six participants (86%) on weight-based dosing had anti-Xa concentrations within the prophylactic range compared with 11 (26%) on BMI-stratified dosing (P<.001). No participant had an anti-Xa concentration of 0.6 international units/mL or greater, the therapeutic threshold for venous thromboembolism prophylaxis. CONCLUSION: In morbidly obese women after cesarean delivery, weight-based dosing of enoxaparin for venous thromboembolism prophylaxis is significantly more effective than BMI-stratified dosing in achieving adequate anti-Xa concentrations. LEVEL OF EVIDENCE: II.

Introduction: obesity and lifestyle issues in women.

To the dismay of clinicians and public health professionals, obesity rates remain high and fundamentally unchanged among women and girls in the United States. The latest data show that 34.9% of adults and 16.9 % of youths are obese. There are marked racial and socioeconomic disparities in obesity in the United States with no appreciable improvements. Although regional variations exist, physical inactivity rates are as high as 43%. Fruit and vegetable consumption was higher in women compared with men, however, the rates remain quite low (36.1% fruit >2/d, 30.9% vegetables >3/d). Obesity impacts health outcomes across the reproductive lifespan.