Maternal self-reported polycystic ovary syndrome with offspring and maternal cardiometabolic outcomes.

STUDY QUESTION: Do children born to mothers with polycystic ovary syndrome (PCOS) have an adverse cardiometabolic profile including arterial stiffness at 9 years of age compared to other children? SUMMARY ANSWER: Children of mothers with PCOS did not have differing cardiometabolic outcomes than children without exposure. WHAT IS KNOWN ALREADY: While women with PCOS themselves have higher risk of cardiometabolic conditions such as obesity and diabetes, the evidence on intergenerational impact is unclear. Given in utero sequalae of PCOS (e.g. hyperandrogenism, insulin resistance), the increased risk could be to both boys and girls. STUDY DESIGN, SIZE, DURATION: The Upstate KIDS cohort is a population-based birth cohort established in 2008-2010 to prospectively study the impact of infertility treatment on children's health. After ∼10 years of follow-up, 446 mothers and their 556 children attended clinical visits to measure blood pressure (BP), heart rate, arterial stiffness by pulse wave velocity (PWV), mean arterial pressure, lipids, high-sensitivity C-reactive protein (hsCRP), hemoglobin A1c (HbA1c), and anthropometrics. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women self-reported ever diagnoses of PCOS ∼4 months after delivery of their children in 2008-2010. Linear regression models applying generalized estimating equations to account for correlation within twins were used to examine associations with each childhood cardiometabolic outcome. MAIN RESULTS AND THE ROLE OF CHANCE: In this cohort with women oversampled on infertility treatment, ∼14% of women reported a PCOS diagnosis (n = 61). We observed similarities in BP, heart rate, PWV, lipids, hsCRP, HbA1c, and anthropometry (P-values >0.05) among children born to mothers with and without PCOS. Associations did not differ by child sex. LIMITATIONS, REASONS FOR CAUTION: The sample size of women with PCOS precluded further separation of subgroups (e.g. by hirsutism). The population-based approach relied on self-reported diagnosis of maternal PCOS even though self-report has been found to be valid. Participants were predominantly non-Hispanic White and a high proportion were using fertility treatment due to the original design. Differences in cardiometabolic health may be apparent later in age, such as after puberty. WIDER IMPLICATIONS OF THE FINDINGS: Our results provide some reassurance that cardiometabolic factors do not differ in children of women with and without self-reported PCOS during pregnancy. STUDY FUNDING/COMPETING INTEREST(S): Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, United States (contracts #HHSN275201200005C, #HHSN267200700019C, #HHSN275201400013C, #HHSN275201300026I/27500004, #HHSN275201300023I/27500017). The authors have no conflicts of interest. REGISTRATION NUMBER: NCT03106493.

Infertility treatment and autism risk using the Modified Checklist for Autism in Toddlers (M-CHAT).

STUDY QUESTION: Are toddlers conceived by fertility treatment at higher risk of failing a screening tool for autism spectrum disorders (ASD) than toddlers not conceived by treatment? SUMMARY ANSWER: Compared with children not conceived by infertility treatment, children conceived by any infertility treatment, ovulation induction with or without intrauterine insemination (OI/IUI), or assisted reproductive technologies (ART) appeared to have had higher odds of failing an ASD screening; however, results were inconclusive and need replication. WHAT IS KNOWN ALREADY: Although most of the studies which have examined risk of ASD after ART show no association, the results are mixed. Thus, further studies are needed to clarify this association. STUDY DESIGN SIZE, DURATION: The Upstate KIDS Study is a population-based, prospective cohort study of children born in New York State between 2008 and 2010. Children were screened for ASD using the Modified Checklist for Autism in Toddlers (M-CHAT) at ages 18 and 24 months. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: The New York State live-birth registry was used to identify newborns conceived with and without fertility treatment with a 1:3 ratio, frequency matched on region of birth. At 18 and 24 months, 3183 and 3063 mothers, respectively, completed the M-CHAT questionnaire. The current analysis included 2586 singletons and 1296 twins with M-CHAT information at 18 and/or 24 months. Multivariable logistic regression with generalized estimating equations (GEE) was used to estimate odds ratios (aOR) and 95% confidence intervals (CI) after adjustment for covariates such as maternal age, education and plurality. MAIN RESULTS AND THE ROLE OF CHANCE: We found that 200 (5.2%) and 115 (3.0%) children failed the M-CHAT at 18 and 24 months, respectively. The associations between use of infertility treatment and failing the M-CHAT at 18 and/or 24 months were positive but inconclusive as they failed to exclude no association (18 months aOR 1.71, 95% CI: 0.81-3.61; 24 months aOR 1.78, 95% CI: 0.66-4.81; and both 18 and 24 months aOR 1.53, 95% CI: 0.78-2.99). The relationships between OI/IUI and ART with M-CHAT failure at 18 and/or 24 months were similar to those of using any fertility treatment. In vitro fertilization with intracytoplasmic sperm injection was not consistently positively or inversely associated with M-CHAT failure at each time point (18 months aOR 1.20, 95% CI: 0.51-2.83; 24 months aOR 0.93, 95% CI: 0.37-2.31; and both 18 and 24 months aOR 1.09, 95% CI: 0.50-2.60). LIMITATIONS REASONS FOR CAUTION: The M-CHAT is a screening tool used for ASD risk assessment, and therefore, M-CHAT failure does not indicate ASD diagnosis. In addition, we did not have power to detect associations of small magnitude. Finally, non-response to follow-up may bias the results. WIDER IMPLICATIONS OF THE FINDINGS: Despite lack of precision, the positive associations between ART and M-CHAT failure suggest that larger population-based studies with longer follow-up are needed. STUDY FUNDING/COMPETING INTEREST(S): Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts HHSN275201200005C, HHSN267200700019C). The sponsor played no role in the study design, data collection, data analysis or interpretation, writing of the manuscript or decision to submit the article for publication. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Impact of parental obesity on neonatal markers of inflammation and immune response.

BACKGROUND/OBJECTIVES: Maternal obesity may influence neonatal and childhood morbidities through increased inflammation and/or altered immune response. Less is known about paternal obesity. We hypothesized that excessive parental weight contributes to elevated inflammation and altered immunoglobulin (Ig) profiles in neonates. SUBJECTS/METHODS: In the Upstate KIDS Study maternal pre-pregnancy body mass index (BMI) was obtained from vital records and paternal BMI from maternal report. Biomarkers were measured from newborn dried blood spots (DBS) among neonates whose parents provided consent. Inflammatory scores were calculated by assigning one point for each of five pro-inflammatory biomarkers above the median and one point for an anti-inflammatory cytokine below the median. Linear regression models and generalized estimating equations were used to estimate mean differences (ß) and 95% confidence intervals (CI) in the inflammatory score and Ig levels by parental overweight/obesity status compared with normal weight. RESULTS: Among 2974 pregnancies, 51% were complicated by excessive maternal weight (BMI>25), 73% by excessive paternal weight and 28% by excessive gestational weight gain. Maternal BMI categories of overweight (BMI 25.0-29.9) and obese class II/III (BMI≥35) were associated with increased neonatal inflammation scores (ß=0.12, 95% CI: 0.02, 0.21; P=0.02 and ß=0.13, CI: -0.002, 0.26; P=0.05, respectively) but no increase was observed in the obese class I group (BMI 30-34.9). Mothers with class I and class II/III obesity had newborns with increased IgM levels (ß=0.11, CI: 0.04, 0.17; P=0.001 and ß=0.12, CI: 0.05, 0.19); P<0.001, respectively). Paternal groups of overweight, obese class I and obese class II/III had decreased neonatal IgM levels (ß=-0.08, CI: -0.13,-0.03, P=0.001; ß=-0.07, CI: -0.13, -0.01, P=0.029 and ß=-0.11, CI:-0.19,-0.04, P=0.003, respectively). CONCLUSIONS: Excessive maternal weight was generally associated with increased inflammation and IgM supporting previous observations of maternal obesity and immune dysregulation in offspring. The role of paternal obesity requires further study.

Infertility treatment and children's longitudinal growth between birth and 3 years of age.

STUDY QUESTION: Does early childhood growth from birth through to 3 years of age differ by mode of conception? SUMMARY ANSWER: Findings suggest early childhood growth was comparable for children irrespective of infertility treatment, but twins conceived with ovulation induction with or without intrauterine insemination (OI/IUI) were slightly smaller than twins conceived without treatment. WHAT IS KNOWN ALREADY: Although studies have found that babies conceived with infertility treatment are born lighter and earlier than infants conceived without treatment, little research especially for non-assisted reproductive technology (ART) treatments has focused on their continued growth during early childhood. STUDY DESIGN, SIZE, DURATION: Upstate KIDS recruited infants born (2008-2010) to resident upstate New York mothers. Infants were sampled based on birth certificate indication of infertility treatment; specifically, for every singleton conceived by infertility treatment, three singletons without infertility treatment were recruited and matched on region of birth. All multiple births irrespective of treatment were also recruited. Children were prospectively followed, returning questionnaires every 4-6 months until 3 years of age. In total, 3905 singletons, 1129 sets of multiples (96% of whom were twins) enrolled into the study. Analyses included 3440 (88%) singletons (969 conceived with treatment; specifically, 433 with ART and 535 with OI/IUI) and 991 (88%) sets of multiples (439 conceived with treatment; specifically 233 with ART and 206 with OI/IUI) with growth data available. PARTICIPANTS/MATERIALS, SETTING, METHODS: Mothers reported infertility treatment use at baseline and children's height and weight from pediatric visits. Self-reported use of ART was previously verified by linkage with the US Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database. Mixed linear models with cubic splines accounting for age and age-gender interactions were used to estimate mean differences in growth from birth to 3 years by infertility treatment status and adjusting for maternal age, race, education, private insurance, smoking status during pregnancy, maternal pre-pregnancy and paternal body mass indices (BMI). MAIN RESULTS AND THE ROLE OF CHANCE: Compared with singletons conceived without treatment (n = 2471), singletons conceived by infertility treatment (433 by assisted reproductive technologies (ART), 535 by OI/IUI and 1 unknown specific type) did not differ in growth. Compared with twins not conceived with treatment (n = 1076), twins conceived with OI/IUI (n = 368) weighed slightly less over follow-up (122 g). They were also proportionally smaller for their length (-0.17 weight-for-length z-score units). No differences in mean size over the 3 years were observed for twins conceived by ART, though some evidence of rapid weight gain from birth to 4 months (adjusted OR 1.08; 95% CI: 1.00-1.16) suggestive of catch up growth was observed. LIMITATIONS, REASONS FOR CAUTION: Participants from upstate New York may not be representative of US infants. Although accounted for in statistical analysis, attrition during follow-up may have limited power to detect small differences. WIDER IMPLICATIONS OF THE FINDINGS: This study is the first to prospectively track the growth of children conceived with and without infertility treatment in the USA, including a substantial number of twins. Our findings are similar to what was previously observed in the ART literature outside of the states. STUDY FUNDING/COMPETING INTERESTS: Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts #HHSN275201200005C, #HHSN267200700019C). Authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Adiposity and sex hormones across the menstrual cycle: the BioCycle Study.

OBJECTIVE: To investigate the influence of adiposity on patterns of sex hormones across the menstrual cycle among regularly menstruating women. SUBJECTS: The BioCycle Study followed 239 healthy women for 1-2 menstrual cycles, with up to eight visits per cycle timed using fertility monitors. METHODS: Serum estradiol (E2), progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and sex hormone-binding globulin (SHBG) were measured at each visit. Adiposity was measured by anthropometry and by dual energy X-ray absorptiometry (DXA). Differences in hormonal patterns by adiposity measures were estimated using nonlinear mixed models, which allow for comparisons in overall mean levels, amplitude (i.e., lowest to highest level within each cycle) and shifts in timing of peaks while adjusting for age, race, energy intake and physical activity. RESULTS: Compared with normal weight women (n=154), obese women (body mass index (BMI) 30 kg m(-2), n=25) averaged lower levels of progesterone (-15%, P=0.003), LH (-17%, P=0.01), FSH (-23%, P=0.001) and higher free E2 (+22%, P=0.0001) across the cycle. To lesser magnitudes, overweight women (BMI: 25-30, n=60) also exhibited differences in the same directions for mean levels of free E2, FSH and LH. Obese women experienced greater changes in amplitude of LH (9%, P=0.002) and FSH (8%, P=0.004), but no differences were observed among overweight women. Higher central adiposity by top compared to bottom tertile of trunk-to-leg fat ratio by DXA was associated with lower total E2 (-14%, P=0.005), and FSH (-15%, P=0.001). Peaks in FSH and LH occurred later (∼0.5 day) in the cycle among women with greater central adiposity. CONCLUSION: Greater total and central adiposity were associated with changes in mean hormone levels. The greater amplitudes observed among obese women suggest compensatory mechanisms at work to maintain hormonal homeostasis. Central adiposity may be more important in influencing timing of hormonal peaks than total adiposity.

Placental characteristics and risks of maternal mortality 50 years after delivery.

INTRODUCTION: Adverse pregnancy outcomes such as preterm delivery and preeclampsia are associated with a higher maternal risk for subsequent cardiovascular disease (CVD) and all-cause mortality. While such pregnancy conditions are related to abnormal placentation, little research has investigated whether pathologic placental measures could serve as a risk factor for future CVD mortality in mothers. METHODS: Longitudinal study of 33,336 women from the Collaborative Perinatal Project (CPP; 1959-1966) linked to mortality information through December 2016. Pathologists took extensive morphological and histopathological measures. Apart from assessing associations with morphological features, we derived an overall composite score and specific inflammation-related, hemorrhage-related, and hypoxia-related pathologic placenta index scores. Cox regression estimated hazard ratios (HR) and 95% confidence intervals (CI) for mortality adjusting for covariates. RESULTS: Thirty-nine percent of women died with mean (standard deviation, SD) time to death of 39 (12) years. Mean (SD) placental weight and birthweight were 436 g (98) and 3156 g (566), respectively. Placenta-to-birthweight ratio was associated with all-cause mortality (adjusted HR 1.03: 1.01, 1.05 per SD in ratio). In cause-specific analyses, it was significantly associated with respiratory (HR 1.06), dementia (HR: 1.10) and liver (HR 1.04) related deaths. CVD, cancer, diabetes and kidney related deaths also tended to increase, whereas infection related deaths did not (HR 0.94; 0.83, 1.06). Placental measures of thickness, diameters, and histopathological measures grouped by inflammatory, hemorrhagic, or hypoxic etiology were not associated with mortality. DISCUSSION: Placental weight in relation to birthweight was associated with long-term maternal mortality but other histopathologic or morphologic features were not.

Life-course weight characteristics and the risk of gestational diabetes.

AIMS/HYPOTHESIS: We prospectively determined the risk of gestational diabetes mellitus in association with life-course weight characteristics and adult abdominal adiposity. METHODS: We investigated the joint and independent impact of birthweight, childhood size by somatotypes, adolescent and adult BMI, and abdominal adiposity on gestational diabetes mellitus risk among the 21,647 women in the Nurses' Health Study II who reported a singleton pregnancy between 1989 and 2001. A total of 1,386 incident cases of gestational diabetes mellitus were reported. Relative risk was estimated by pooled logistic regression adjusting for age, prematurity, race, smoking status, parental history of diabetes, age of first birth, parity and physical activity. RESULTS: Birthweight was inversely associated with gestational diabetes mellitus risk (p = 0.02 for trend). Childhood somatotypes at ages 5 and 10 years were not associated with risk. U-shaped associations were found for BMI at age 18 years and somatotype at age 20 years. Weight gain between adolescence and adulthood, pre-gravid BMI and abdominal adiposity were positively associated with risk (p < 0.01 for all trends). Multivariate adjusted RRs for gestational diabetes from lowest to highest quintile of WHR were 1.00, 1.50, 1.51, 2.03, 2.12 (p = 0.0003 for trend). Lower birthweight (<7 lb) without adulthood overweight (BMI > 25 kg/m(2)) was associated with a 20% increased risk (95% CI 1.02-1.41). However, adulthood overweight alone was related to a 2.36 times greater risk (95% CI 2.12-3.77). CONCLUSIONS/INTERPRETATION: Although lower birthweight is an independent risk factor for gestational diabetes mellitus, weight gain since early adulthood, and overall and central obesity in adulthood were more strongly associated with elevated risk of the condition independently of other known risk factors.

Newborn adipokines and early childhood growth.

BACKGROUND: While adipokines can regulate satiety and energy metabolism, whether they are associated with childhood growth is unclear. OBJECTIVE: To evaluate whether adipokine levels at birth are associated with growth. METHODS: A total of 2264 singletons and 1144 twins from Upstate KIDS (born 2008-2010) had adiponectin, leptin, resistin and complement factor D measured in newborn blood spots. Parents reported anthropometry from paediatric visits via questionnaires every 4-6 months. Generalized linear mixed effects models were used to estimate growth trajectories through 3 years of age. RESULTS: Among singletons, resistin and leptin were associated with greater weight-for-age (0.12 z-score units (95%CI: 0.04, 0.20) [p = 0.003] and 0.15 (0.06, 0.24) [p = 0.001], respectively) and BMI z-score (0.11; 0.02, 0.20 [p = 0.02] and 0.18; 0.07, 0.28 [p = 0.002], respectively). After adjusting for birthweight, resistin and a ratio of resistin-to-adiponectin remained associated with weight through 3 years of age and odds of being overweight at 3 years of age in a subgroup of singletons. Among twins, adiponectin was associated with increased weight-for-age and length-for-age z-scores even after adjusting for birthweight (0.18; 0.08, 0.28 [p = 0.0006]; 0.20; 0.07, 0.33 [p = 0.003], respectively). CONCLUSIONS: Levels of adipokines were associated with early childhood growth in small magnitudes. Resistin may be relevant for further examination in paediatric obesity.

Prenatal fish oil supplementation and early childhood development in the Upstate KIDS Study.

Fish oil contains omega-3 fatty acids, which play a vital role in fetal growth and development. In utero exposure to omega-3 fatty acids is exclusively dependent on maternal nutrition. Previous studies have suggested that prenatal fish oil supplementation has positive impacts on child neurodevelopment later in life. This study examines the associations between fish oil supplementation both before pregnancy and throughout pregnancy and subsequent child development. Mother-child pairs from the Upstate KIDS Study, a birth cohort consisting of children born between 2008 and 2010, were included. Self-reported prenatal fish oil supplementation data were available for 5845 children (3807 singletons and 2038 twins). At multiple time points, from 4 months to 3 years of age, child development was reported by the parents on the Ages and Stages Questionnaire (ASQ). Five developmental domains were assessed: fine motor, gross motor, communication, personal-social functioning and problem solving. Generalized linear mixed models were used to estimate odds ratios (OR) while adjusting for covariates. Primary analyses showed that the risk of failing the ASQ problem-solving domain was significantly lower among children of women who took fish oil before pregnancy (OR 0.40, 95% confidence intervals (CI) 0.18-0.89) and during pregnancy (OR 0.43, 95% CI 0.22-0.83). Gender interaction was not statistically significant, although stratified results indicated stronger associations among girls. Similarly, associations were primarily among singletons. Prenatal fish oil supplementation may be beneficial in regards to neurodevelopment. Specifically, it is associated with a lower risk of failing the problem-solving domain up to 3 years of age.

Maternal serum markers of lipid metabolism in relation to neonatal anthropometry.

OBJECTIVE: The objective of this study is to examine associations between lipids (high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides and lipoprotein (a)) measured on average three time points during pregnancy and neonatal anthropometrics. STUDY DESIGN: Stored samples from a preeclampsia trial measured as part of a case-control study from five US centers (1992 to 1995) were used. The sample included women without pregnancy complications (n=136) and cases of gestational diabetes (n=93), abnormal glucose tolerance (AGT; n=76), gestational hypertension (n=170) and preeclampsia (n=177). Linear regression and linear mixed-effects models estimated adjusted associations between lipids and birth weight z-score, ponderal index (PI), length and head circumference. RESULTS: Among women without complications, cross-sectional associations between total cholesterol measured at different gestational ages increased PI 2.23 to 2.55 kg m-3 per-unit increase in cholesterol. HDL was inversely associated with birth length (ß's=-2.21 and -2.56 cm). For gestational hypertension, triglycerides were associated with birth weight z-score (ß's=0.24 to 0.31). For preeclampsia, HDL was associated with lower birth weight z-scores (ß's=-0.49 and -0.82). Women with gestational diabetes or AGT had inconsistent associations. Examining the level changes across pregnancy, each 0.0037 mmol l-1 increase in HDL was associated with decreased birth weight z-score (ß=-0.22), length (ß=-0.24 cm) and head circumference (ß=-0.24 cm), whereas each 0.028 mmol l-1 increase in triglycerides was associated with increased birth weight z-score (ß=0.13) and head circumference (ß=0.19 cm). CONCLUSIONS: Although associations varied by complications, in general, growth-promoting fuels such as total cholesterol and triglycerides were associated with increased neonatal size, whereas high HDL was associated with smaller size. Maternal HDL that failed to decrease over pregnancy was associated with smaller neonate size.

Radiographic assessment of congenital talipes equinovarus: strapping versus forced dorsiflexion.

PURPOSE: To compare 2 radiographic assessment methods for congenital talipes equinovarus: strapping the ankle with tapes versus dorsiflexion with a wooden block. METHODS: Anteroposterior and lateral radiographs were taken with the ankle strapped by tapes or dorsiflexed by a wooden block. Talocalcaneal and tibiocalcaneal angles were measured and analysed. RESULTS: 20 radiographic assessments were performed on 14 patients. From the anteroposterior view, the mean talocalcaneal angle with strapping was 19.4 degrees (range, 0-34.0 degrees; standard deviation [SD], 11.2 degrees). From the lateral view, the mean talocalcaneal angle with strapping was 22.0 degrees (range, 8.0-38.8 degrees; SD, 8.9 degrees) and with forced dorsiflexion was 21.0 degrees (range, 0-52.7 degrees; SD, 11.3 degrees), with a mean absolute difference of 9.4 degrees between the 2 groups. The mean tibiocalcaneal angle with strapping was 77.9 degrees (range, 43.2-120.0 degrees; SD, 18.8 degrees) and with forced dorsiflexion was 78.2 degrees (range, 29.5-134.0 degrees; SD, 24.7 degrees), with a mean absolute difference of 15.7 degrees between the 2 groups. The difference between the tibiocalcaneal measurements in the 2 groups was statistically significant (p=0.026). CONCLUSION: Similar results were obtained for talocalcaneal and tibiocalcaneal angles measured with strapping and forced dorsiflexion. However, the strapping method provides better stabilisation while radiographs are taken.

Adherence to the Mediterranean diet and body fat distribution in reproductive aged women.

BACKGROUND/OBJECTIVES: Adherence to the Mediterranean diet (MD), high in fruits, vegetables and monounsaturated fats, has been associated with lower body mass index. Associations with measured body fat, including regional adiposity, have not been previously investigated. We examined the associations between the alternate Mediterranean diet score (aMED), anthropometry and measured adiposity by dual-energy x-ray absorptiometry (DXA). SUBJECTS/METHODS: This study included 248 healthy females, aged 18-44 years from the BioCycle Study. Each woman's aMED (range 0-9) was calculated from up to eight 24-h dietary recalls over 1-2 menstrual cycles (>97% had ≥ 7 recalls). Multiple linear regression was used to determine whether aMED and its specific components were associated with total and regional adiposity after adjusting for age, race, education, physical activity and energy intake. RESULTS: Participants had an average (s.d.) aMED of 4.2 (1.7) and percent body fat of 29.5 (6.0)%. Significant inverse associations were found between aMED and all the examined adiposity measures except waist-to-hip ratio. Among the DXA measures, a 1-unit increment in aMED was associated with a 0.06 (95% confidence interval (CI): -0.09, -0.02) lower trunk-to-leg fat ratio (T/L), a measure of upper to lower body fat. In an analysis examining T/L as an outcome with the separate components of the aMED, T/L was lower with increased legume consumption (ß=-0.280, 95% CI: -0.550, -0.010) but was higher with increased consumption of red and processed meat (ß=0.060, 95% CI: 0.002, 0.117). CONCLUSIONS: Adherence to the aMED was associated with lower total and regional adiposity, adding to the mounting evidence of the health benefits of the MD.