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Dieberger AM, Obermayer-Pietsch B, Harreiter J, Desoye G, van Poppel MNM. Physical activity and sedentary time across pregnancy and associations with neonatal weight, adiposity and cord blood parameters: a secondary analysis of the DALI study. Int J Obes (Lond) 2023; 47:873-881. [PMID: 37500924 PMCID: PMC10439006 DOI: 10.1038/s41366-023-01347-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 05/10/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND/OBJECTIVES Obesity during pregnancy is associated with neonatal adiposity, which is a risk factor for childhood obesity. Maternal physical activity (PA) and sedentary behaviours during pregnancy might modify this risk. We therefore studied associations between maternal PA and sedentary time (ST) during pregnancy and neonatal anthropometry and cord blood parameters and investigated whether associations differed by offspring sex. SUBJECTS/METHODS Participants of the Vitamin D And Lifestyle Intervention for Gestational Diabetes Mellitus Prevention (DALI) study with a BMI ≥ 29 kg/m2 were analysed as a cohort. Maternal moderate-to-vigorous PA (MVPA) and ST were measured repeatedly with accelerometers across pregnancy. Associations between mean levels and changes in MVPA and ST and birthweight, neonatal adiposity (fat mass (FM)%) and cord blood parameters, including C-peptide, leptin and lipids, were analysed in 213 mother-child pairs with Bayesian multilevel models. Interactions with offspring sex were considered. RESULTS Almost all women decreased MVPA levels and increased ST throughout gestation. Both higher maternal mean MVPA and increasing MVPA were associated with lower offspring FM% in males (-0.520%; 95% CI: -1.011%, -0.031% and -4.649%; -7.876%, -1.432% respectively). In female offspring, mean ST was associated with lower cord blood C-peptide (-0.145 µg/l; -0.279 µg/l, -0.005 µg/l). No associations were found with birthweight or other cord blood parameters. CONCLUSIONS Maternal MVPA is associated with neonatal fat mass, but not birthweight, in male offspring. Our findings underline the importance of physical activity throughout pregnancy.
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Affiliation(s)
- Anna M Dieberger
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine and Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria
| | - Jürgen Harreiter
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gernot Desoye
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria
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Peter-Marske KM, Hesketh KR, Herring AH, Savitz DA, Bradley CB, Evenson KR. Association Between Change in Physical Activity During Pregnancy and Infant Birth Weight. Matern Child Health J 2023; 27:659-670. [PMID: 36738421 PMCID: PMC10023475 DOI: 10.1007/s10995-023-03604-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We assessed whether total, recreational, and non-recreational physical activity (PA) assessed twice during pregnancy, and its change, were associated with infant birth weight and small for gestational age (SGA). METHODS We included 1467 Pregnancy, Infection, and Nutrition 3 Study participants who self-reported PA at time 1 (T1: 17-22 weeks' gestation) and time 2 (T2: 27-30 weeks' gestation). We assessed last week absolute intensities of PA (moderate: 4.7-7.1 METs; and vigorous: > 7.1 METs) and perceived intensities. Change in hours/week of PA was assessed continuously or categorically (increase or decrease ≥ 1 hour, and no change). Associations of continuous PA hours/week at T1, T2, and its change, with sex-specific z-scores of birth weight, were assessed using multivariable linear robust regressions. We used logistic regressions to assess categorical PA measures with SGA. Models were adjusted for adequacy of maternal weight gain, general health, maternal age, parity, race/ethnicity, and smoking. RESULTS Hours/week of total and recreational absolute intensities of PA at T1, T2, and its change were generally not associated with birth weight, although two measures of non-recreational PA at T2 and its change were associated with increased birth weight. Perceived intensities of PA (at T1, T2, and its change) were largely not associated with sex-specific z-scores of infant birth weight. Absolute and perceived intensity PA were not associated with SGA. CONCLUSIONS FOR PRACTICE In this observational cohort, increases and decreases in PA during pregnancy were not associated with differential changes in birthweight or SGA.
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Affiliation(s)
- Kennedy M Peter-Marske
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kathryn R Hesketh
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | | | | | - Chyrise B Bradley
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kelly R Evenson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Physical Activity during Pregnancy and Newborn Body Composition: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127127. [PMID: 35742376 PMCID: PMC9222359 DOI: 10.3390/ijerph19127127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022]
Abstract
The current literature demonstrates that not only is exercise during pregnancy safe, but it has substantial maternal and infant benefits and appears to influence infant growth/size throughout pregnancy and at birth. However, many existing studies have investigated only the effects of prenatal exercise on birth weight. The purpose of this review was to determine the impact or association of maternal physical activity during pregnancy on neonatal body composition assessed between birth and two weeks of age. Electronic database searches were conducted on 29 July 2019 for randomized control trials and cohort studies, with an updated search completed on 8 January 2021. A total of 32 articles that met eligibility criteria were selected for review. Overall, prenatal exercise was not associated with infant body composition at birth. Yet, five of the studies identified suggest that infant body composition could be influenced by higher volumes of mid-to-late term prenatal physical activity. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (Registration No. CRD42020160138).
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Chen Y, Ma G, Hu Y, Yang Q, Deavila JM, Zhu MJ, Du M. Effects of Maternal Exercise During Pregnancy on Perinatal Growth and Childhood Obesity Outcomes: A Meta-analysis and Meta-regression. Sports Med 2021; 51:2329-2347. [PMID: 34143412 DOI: 10.1007/s40279-021-01499-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perinatal growth abnormalities program susceptibility to childhood obesity, which is further exaggerated by maternal overweight and obesity (MO) during pregnancy. Exercise is highly accessible, but reports about the benefits of maternal exercise on fetal growth and childhood obesity outcomes are inconsistent, reducing the incentives for pregnant women to participate in exercise to improve children's perinatal growth. OBJECTIVE This systematic review and meta-analysis aims to establish evidence-based efficacy of exercise in mothers with normal weight (MNW) and MO during pregnancy in reducing the risks of perinatal growth abnormalities and childhood obesity. In addition, the impacts of exercise volume are also assessed. METHODS The PubMed, ScienceDirect, Web of Science, and Cochrane Library databases were searched from inception to February 15, 2020. We included randomized controlled trials with exercise-only intervention or exercise with other confounders in pregnant MNW (body mass index, BMI 18.5-24.9 kg/m2) and MO (BMI ≥ 25 kg/m2), which were further subgrouped in the meta-analysis. Primary outcomes included birth weight, preterm birth, small for gestational age (SGA), large for gestational age (LGA), infant and childhood weight, and childhood obesity. A linear meta-regression analysis was also used to explore the effects of exercise volume on outcomes. RESULTS 99 studies were included in the meta-analysis (n = 596,876), and individual study quality ranged from fair to good according to the Newcastle-Ottawa scale assessment. Exercise only interventions in MNW reduced preterm birth by 15% (26 studies, n = 76,132; odds ratio [OR] 0.85; 95% CI 0.72, 1.01; I2 = 83.3%), SGA by 17% (33 studies, n = 92,351; OR 0.83; 95% CI 0.71, 0.98; I2 = 74.5%) and LGA by 17% (29 studies, n = 84,310; OR 0.83; 95% CI 0.74, 0.95; I2 = 60.4%). Exercise only interventions in MO reduced preterm birth by 33% (2 studies, n = 3,050; OR 0.67; 95% CI 0.70, 0.96; I2 = 0%), SGA by 27% (8 studies, n = 3,909; OR 0.73; 95% CI 0.50, 1.05; I2 = 40.4%) and LGA by 55% (9 studies, n = 81,581; OR 0.45; 95% CI 0.18, 1.11; I2 = 98.3%). Exercise only interventions in MNW reduced childhood obesity by 53% (3 studies, n = 6,920; OR 0.47; 95% CI 0.36, 0.63; I2 = 77.0%). However, no significant effect was observed in outcomes from exercise confounders in either MNW or MO. In the meta-regression, the volume of exercise-only intervention in MNW was negatively associated with birth weight, greatly driven by volumes more than 810 metabolic equivalents (MET)-min per week. Other outcomes were not associated with exercise volume. CONCLUSIONS This systematic review and meta-analysis suggests that exercise during pregnancy in both MNW and MO safely and effectively reduce the risks of preterm birth, SGA, and LGA. Furthermore, MNW exercise also reduces the risk of childhood obesity. Overall, regardless of prepregnancy BMI, maternal exercise during pregnancy provides an excellent opportunity to mitigate the high prevalence of adverse birth outcomes and childhood obesity.
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Affiliation(s)
- Yanting Chen
- Center for Reproductive Biology, School of Molecular Biosciences, Washington State University, Pullman, WA, 99164, USA.,Nutrigenoimics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, 99164, USA
| | - Guiling Ma
- College of Animal Science and Technology, Yangzhou University, Yangzhou, 225009, People's Republic of China
| | - Yun Hu
- College of Animal Science and Technology, Yangzhou University, Yangzhou, 225009, People's Republic of China
| | - Qiyuan Yang
- Department of Molecular, Cell and Cancer Biology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Jeanene M Deavila
- Center for Reproductive Biology, School of Molecular Biosciences, Washington State University, Pullman, WA, 99164, USA.,Nutrigenoimics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, 99164, USA
| | - Mei-Jun Zhu
- School of Food Science, Washington State University, Pullman, WA, 99164, USA
| | - Min Du
- Center for Reproductive Biology, School of Molecular Biosciences, Washington State University, Pullman, WA, 99164, USA. .,Nutrigenoimics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, 99164, USA.
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Francis EC, Zhang L, Witrick B, Chen L. Health behaviors of American pregnant women: a cross-sectional analysis of NHANES 2007-2014. J Public Health (Oxf) 2021; 43:131-138. [PMID: 31832663 DOI: 10.1093/pubmed/fdz117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 07/10/2019] [Accepted: 08/15/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study examined engagement in five health behaviors among pregnant women in the USA. METHODS Pregnant women who participated in the National Health and Nutrition Examination Survey 2007-2014 were included in this study. Five health behaviors were examined: adequate fruit and vegetable consumption, prenatal multivitamin use, physical activity, sleep and smoking. Multivariable regressions were used to estimate the odds ratio and 95% confidence interval of characteristics associated with health behaviors. RESULTS Among 248 pregnant women, only 10.2% engaged in all five health behaviors and 35.4% consumed adequate fruits and vegetables. For adequate fruit and vegetable consumption, Hispanic and women of 'other' race were more likely to meet the recommendation compared to non-Hispanic white (P = 0.01 and P = 0.03, respectively); high school graduates were less likely to meet the recommendation compared to those with at least some college education or more (P = 0.04). CONCLUSIONS Adequate fruit and vegetable consumption among pregnant women was poor and differed by race/ethnicity and education status. Because of the cross-sectional design, we cannot examine engagement in health behaviors continuously throughout pregnancy. Future research with longitudinal data over the course of pregnancy is needed to confirm these results.
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Affiliation(s)
- Ellen C Francis
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Lu Zhang
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Brian Witrick
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Liwei Chen
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
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Patient Attitudes toward Gestational Weight Gain and Exercise during Pregnancy. J Pregnancy 2019; 2019:4176303. [PMID: 31637057 PMCID: PMC6766150 DOI: 10.1155/2019/4176303] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/30/2019] [Indexed: 02/08/2023] Open
Abstract
Body mass index (BMI) and gestational weight gain (GWG) are important factors for neonatal and maternal health. Exercise helps women moderate their BMI and GWG, and provides health benefits to mother and child. This survey study assessed patients' perceptions of counseling they received during pregnancy, their sources of information about GWG, and their attitudes toward exercise during pregnancy. We distributed an anonymous survey to 200 pregnant women over the age of 18 at a tertiary care center in Danville, Pennsylvania. Survey questions included demographics, discussions with medical providers regarding GWG and exercise, and their exercise habits before and during pregnancy. 182 women (91%) responded. Most reported their provider discussed weight and diet (78.8%), expected GWG (81.6%), and exercise during pregnancy (79.8%); however, 28% of obese women and 25% of women who did not plan to exercise during pregnancy reported not receiving exercise counseling. Approximately 20% of women did not plan to exercise during pregnancy. Women decreased the number of days per week they exercised (40.6% with 3 or more days prepregnancy versus 30.7% during pregnancy, P = 0.002). Some patients who did not exercise prior to pregnancy (12%) expressed interest in a personal training session. Among women in the eight month or later, 42.4% were above GWG recommendations. Our study found barriers to adequate activity during pregnancy; 20% of pregnant women not receiving/remembering counseling regarding exercise. Interest in personal training from patients that did not exercise suggests they would benefit from increased efforts to encourage physical activity. Exercise and GWG counseling based in medical science as well as patient psychological needs will help efforts to reduce GWG and improve pregnancy outcomes.
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Flannery C, Dahly D, Byrne M, Khashan A, McHugh S, Kenny LC, McAuliffe F, Kearney PM. Social, biological, behavioural and psychological factors related to physical activity during early pregnancy in the Screening for Pregnancy Endpoints (Cork, Ireland) cohort study. BMJ Open 2019; 9:e025003. [PMID: 31227527 PMCID: PMC6596951 DOI: 10.1136/bmjopen-2018-025003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify the social, biological, behavioural and psychological factors related to physical activity (PA) in early pregnancy. DESIGN This is a secondary analysis of data from a prospective cohort study. SETTING The study was conducted in Cork, Ireland. PARTICIPANTS Nulliparous women with singleton pregnancies were recruited and then interviewed at 15±1 weeks' gestation. PRIMARY AND SECONDARY OUTCOMES The biopsychosocial model identified factors including social (age), biological (body mass index), behavioural (diet) and psychological (anxiety) at 15±1 weeks' gestation. PA subgroups were identified based on a latent class analysis of their responses to a set of questions about the amount and intensity of activity they were engaging in during the pregnancy. Associations were estimated with multivariable multinomial logistic regression models. RESULTS From a total of 2579, 1774 (69%) women were recruited; ages ranged from 17 to 45 years. Based on a combination of model fit, theoretical interpretability and classification quality, the latent class analyses identified three PA subgroups: low PA (n=393), moderate PA (n=960) and high PA (n=413). The fully adjusted model suggests non-smokers, and consumers of fruit and vegetables were more likely to be in the high PA subgroup (vs low). Women with more than 12 years of schooling and a higher socioeconomic status were more likely to be in the moderate PA subgroup (vs low). CONCLUSION The findings highlight potential links between PA, a low education level and a low socioeconomic background. These factors should be considered for future interventions to improve low PA levels during pregnancy. TRIAL REGISTRATION NUMBER ACTRN 12607000551493.
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Affiliation(s)
- Caragh Flannery
- School of Psychology, Health Behaviour Change Research Group, National University of Ireland Galway, Galway, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | - Darren Dahly
- School of Public Health, University College Cork, Cork, Ireland
- Health Research Board, Clinical Research Facility Cork, University College Cork, Cork, Ireland
| | - Molly Byrne
- School of Psychology, Health Behaviour Change Research Group, National University of Ireland Galway, Galway, Ireland
| | - Ali Khashan
- School of Public Health, University College Cork, Cork, Ireland
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - Louise C Kenny
- Department of Women’s and Children’s Health, University of Liverpool School of Life Sciences, Liverpool, UK
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
- National Maternity Hospital, University College Dublin, Dublin, Ireland
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Catov JM, Parker CB, Gibbs BB, Bann CM, Carper B, Silver RM, Simhan HN, Parry S, Chung JH, Haas DM, Wapner RJ, Saade GR, Mercer BM, Bairey-Merz CN, Greenland P, Ehrenthal DB, Barnes SE, Shanks AL, Reddy UM, Grobman WA. Patterns of leisure-time physical activity across pregnancy and adverse pregnancy outcomes. Int J Behav Nutr Phys Act 2018; 15:68. [PMID: 29996930 PMCID: PMC6042402 DOI: 10.1186/s12966-018-0701-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/29/2018] [Indexed: 11/29/2022] Open
Abstract
Background Although leisure-time physical activity (PA) contributes to overall health, including pregnancy health, patterns across pregnancy have not been related to birth outcomes. We hypothesized that women with sustained low leisure-time PA would have excess risk of adverse pregnancy outcomes, and that changing patterns across pregnancy (high to low and low to high) may also be related to risk of adverse pregnancy outcomes. Methods Nulliparous women (n = 10,038) were enrolled at 8 centers early in pregnancy (mean gestational age in weeks [SD] = 12.05 [1.51]. Frequency, duration, and intensity (metabolic equivalents) of up to three leisure activities reported in the first, second and third trimesters were analyzed. Growth mixture modeling was used to identify leisure-time PA patterns across pregnancy. Adverse pregnancy outcomes (preterm birth, [PTB, overall and spontaneous], hypertensive disorders of pregnancy [HDP], gestational diabetes [GDM] and small-for-gestational-age births [SGA]) were assessed via chart abstraction. Results Five patterns of leisure-time PA across pregnancy were identified: High (35%), low (18%), late decreasing (24%), early decreasing (10%), and early increasing (13%). Women with sustained low leisure-time PA were younger and more likely to be black or Hispanic, obese, or to have smoked prior to pregnancy. Women with low vs. high leisure-time PA patterns had higher rates of PTB (10.4 vs. 7.5), HDP (13.9 vs. 11.4), and GDM (5.7 vs. 3.1, all p < 0.05). After adjusting for maternal factors (age, race/ethnicity, BMI and smoking), the risk of GDM (Odds ratio 2.00 [95% CI 1.47, 2.73]) remained higher in women with low compared to high patterns. Early and late decreasing leisure-time PA patterns were also associated with higher rates of GDM. In contrast, women with early increasing patterns had rates of GDM similar to the group with high leisure-time PA (3.8% vs. 3.1%, adjusted OR 1.16 [0.81, 1.68]). Adjusted risk of overall PTB (1.31 [1.05, 1.63]) was higher in the low pattern group, but spontaneous PTB, HDP and SGA were not associated with leisure-time PA patterns. Conclusions Sustained low leisure-time PA across pregnancy is associated with excess risk of GDM and overall PTB compared to high patterns in nulliparous women. Women with increased leisure-time PA early in pregnancy had low rates of GDM that were similar to women with high patterns, raising the possibility that early pregnancy increases in activity may be associated with improved pregnancy health. Trial registration Registration number NCT02231398. Electronic supplementary material The online version of this article (10.1186/s12966-018-0701-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janet M Catov
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 204 Craft Avenue, Suite A208, Pittsburgh, PA, 15213, USA.
| | | | - Bethany Barone Gibbs
- Department of Health and Physical Activity, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | | | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 204 Craft Avenue, Suite A208, Pittsburgh, PA, 15213, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Judith H Chung
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, University of Texas, Galveston, TX, USA
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH, USA
| | - C Noel Bairey-Merz
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Philip Greenland
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Shannon E Barnes
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Anthony L Shanks
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - William A Grobman
- Department of Obstetrics, Gynecology-Maternal Fetal Medicine & Preventive Medicine, Northwestern University, Chicago, IL, USA
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