Achieving a healthy weight gain during pregnancy

A new care pathway to optimize gestational weight gain in twin pregnancies

BACKGROUND

Maternal gestational weight gain is an important determinant of pregnancy outcomes and may have an even greater role in twin pregnancies because of their higher rate of pregnancy complications and greater nutritional demands. However, data on the optimal week-specific gestational weight gain in twin pregnancies and on interventions that should be applied in cases of inadequate gestational weight gain are limited.

OBJECTIVE

This study aimed to determine whether a new care pathway that involves monitoring gestational weight gain using a week-specific chart, along with a standardized protocol for managing cases with inadequate gestational weight gain, can optimize maternal gestational weight gain in twin pregnancies.

METHODS

In this study, patients with twin pregnancies followed in a single tertiary center between February 2021 and May 2022 were exposed to the new care pathway (postintervention group). Gestational weight gain and clinical outcomes were compared with those of a previously described cohort of patients with twins followed in our clinic before the implementation of the new care pathway (preintervention group). The new care pathway targeted patients and care providers and included educational material, a newly developed body mass index group-specific gestational weight gain chart, and a stepwise management algorithm in cases of inadequate gestational weight gain. The body mass index group-specific gestational weight gain charts were divided into 3 zones: (1) green zone (optimal gestational weight gain at 25th-75th centiles); (2) yellow zone (suboptimal gestational weight gain at 5th-24th or 76th-95th centiles); and (3) gray zone (abnormal gestational weight gain, at <5th or >95th centile). The primary outcome was the overall proportion of patients achieving optimal gestational weight gain at birth.

RESULTS

A total of 123 patients were exposed to the new care pathway and were compared with 1079 patients from the preintervention period. Patients in the postintervention group were more likely to achieve optimal gestational weight gain at birth (60.2% vs 47.7%; adjusted odds ratio, 1.91; 95% confidence interval, 1.28-2.86) and were less likely to achieve low-suboptimal gestational weight gain (7.3% vs 14.7%; adjusted odds ratio, 0.41; 95% confidence interval, 0.20-0.85) or any suboptimal gestational weight gain (26.8% vs 34.8%; adjusted odds ratio, 0.60; 95% confidence interval, 0.39-0.93) at birth. In addition, patients in the postintervention group were less likely to have low-abnormal gestational weight gain anytime during gestation (18.9% vs 29.1%; P=.017) and were more likely to have normal gestational weight gain throughout pregnancy (21.3% vs 14.0%; P=.031) or high-abnormal gestational weight gain anytime during gestation (18.0% vs 11.1%; P=.025), suggesting that in comparison with standard care, the new care pathway is more effective in preventing patients from moving into the low-abnormal zone than the high-abnormal zone. Furthermore, the new care pathway was more effective than standard care in correcting high-suboptimal gestational weight gain and high-abnormal gestational weight gain.

CONCLUSION

Our findings suggest that the new care pathway may be effective in optimizing maternal gestational weight gain in twin gestations, which may in turn contribute to better clinical outcomes. This is a simple, low-cost intervention that can be easily disseminated among providers caring for patients with twin pregnancies.

Associations of maternal stress and/or depressive symptoms with diet quality during pregnancy: a narrative review

BACKGROUND

Pregnancy can be a stressful time for many women; however, it is unclear if higher stress and depressive symptoms are associated with poorer diet quality during pregnancy.

OBJECTIVE

The aims for this narrative review were to (1) synthesize findings of original, peer-reviewed studies that examined associations of stress and/or depressive symptoms with diet quality during pregnancy; (2) review the measurement tools used to assess stress, depressive symptoms, and diet quality; (3) identify current gaps in the extant literature; and (4) offer recommendations for future research.

METHODS

A search strategy was used to identify peer-reviewed manuscripts published between January 1997 and October 2018, using the following databases: PubMed, CINAHL Complete, PsycINFO, Academic Search Complete, and Psychology & Behavioral Sciences Collection. The search was updated December 2019. Two reviewers independently assessed title, abstract, and full-text of the studies that met the inclusion criteria. Data were extracted and a quality assessment was conducted.

RESULTS

Twenty-seven observational studies were identified in this review (21 cross-sectional and 6 longitudinal). In 22 studies, higher stress and/or depressive symptoms were associated with poorer diet quality or unhealthy dietary patterns; 5 studies found no association. Findings are mixed and inconclusive regarding the relationship among stress, depressive symptoms, and food groups related to diet quality and frequency of fast-food consumption.

CONCLUSIONS

The current data suggest stress and depressive symptoms may be a barrier to proper diet quality during pregnancy; however, variability in the assessment tools, timing of assessments, and use of covariates likely contribute to the inconsistency in study findings. Gaps in the literature include limited use of longitudinal study designs, limited use of comprehensive diet-quality indices, underrepresentation of minority women, and lack of multilevel theoretical frameworks. Studies should address these factors to better assess associations of stress and/or depressive symptoms with diet quality during pregnancy.

Investigating the normalization and normative views of gestational weight gain: Balancing recommendations with the promotion and support of healthy pregnancy diets

OBJECTIVES

Gestational weight gain (GWG) is increasingly monitored in the United States and Canada. While promoting healthy GWG offers benefits, there may be costs with over-surveillance. We aimed to explore these costs/benefits.

METHODS

Quantitative data from 350 pregnant survey respondents and qualitative focus group data from 43 pregnant/post-partum and care-provider participants were collected in the Mothers to Babies (M2B) study in Hamilton, Canada. We report descriptive statistics and discussion themes on GWG trajectories, advice, knowledge, perceptions, and pregnancy diet. Relationships between GWG monitoring/normalization and worry, knowledge, diet quality, and sociodemographics-namely low-income and racialization-were assessed using χ² tests and a linear regression model and contextualized with focus group data.

RESULTS

Most survey respondents reported GWG outside recommended ranges but rejected the mid-20th century cultural norm of "eating for two"; many worried about gaining excessively. Conversely, respondents living in very low-income households were more likely to be gaining less than recommended GWG and to worry about gaining too little. A majority had received advice about GWG, yet half were unable to identify the range recommended for their prepregnancy BMI. This proportion was even lower for racialized respondents. Pregnancy diet quality was associated with household income, but not with receipt or understanding of GWG guidance. Care-providers encouraged normalized GWG, while worrying about the consequences of pathologizing "abnormal" GWG.

CONCLUSIONS

Translation of GWG recommendations should be done with a critical understanding of GWG biological normalcy. Supportive GWG monitoring and counseling should consider clinical, socioeconomic, and community contexts.

A Behavioral Lifestyle Intervention to Limit Gestational Weight Gain in Pregnant Women with Overweight and Obesity

OBJECTIVE

This study aimed to evaluate the effects of an antenatal behavioral lifestyle intervention on total gestational weight gain (GWG) and perinatal outcomes.

METHODS

Pregnant women with overweight and obesity in South Carolina were recruited into a theory-based randomized controlled trial (n = 112 intervention, n = 105 standard care), which was designed to target weight self-monitoring, increased physical activity, and improved dietary practices.

RESULTS

Participants were racially/ethnically diverse (44% African American). Intervention and standard care participants had similar total GWG at delivery (12.9 ± 6.9 vs. 12.4 ± 8.3 kg, respectively), but intervention participants had a smaller standard deviation (P = 0.04) in total GWG. The treatment effects were moderated by race/ethnicity and prepregnancy BMI. Among African American participants with overweight, intervention participants gained 4.5 kg less, whereas, among African American women with obesity, intervention participants gained 4.1 kg more than standard care participants. Total GWG among White participants was similar regardless of weight status and group assignment. Fewer intervention participants than standard care participants had adverse pregnancy outcomes (P ≤ 0.01).

CONCLUSIONS

The behavioral lifestyle intervention favorably impacted GWG in African American participants with overweight but not African American participants with obesity. The intervention's overall favorable impact on perinatal outcomes suggests that the mechanisms beyond total GWG may drive these outcomes.

Gestational weight gain and eating-related disorders

This prospective cohort study took place at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy, from January to November 2018. In the second day postpartum, 463 healthy at term puerperae, 122 (26.35%) with inadequate gestational weight gain (GWG), 210 (45.46%) with adequate GWG, and 131 (28.29%) with excessive GWG, were studied by EAT-26, through distinguishing three factors: 'Dieting', 'Bulimia and food preoccupation', and 'Oral control'. EAT-26 Global score increased from inadequate, to adequate, and excessive GWG puerperae, resulting significantly higher in excessive GWG group (p = .0029, Anova's). In addition, among EAT-26 subscales 'Dieting' scores significantly increased from inadequate, to adequate, and to excessive GWG category women, resulting significantly higher in excessive GWG group (p = .006, Anova's). It was found that excessive GWG is a warning indicator of unhealthy eating and 'Dieting' disorders. This relationship highlights the potential for interventions directed towards psychosocial support to have salutary effects upon GWG.Excessive gestational weight gain across an uncomplicated pregnancy is a warning indicator of unhealthy eating and dieting disorders.IMPACT STATEMENTWhat is already known on this subject? Pregnancy represents a time of rapid trimester-specific changes in body weight and size.What do the results of this study add? Excessive gestational weight gain is a warning indicator of unhealthy eating and dieting disorders.What are the implications of these findings for clinical practice and/or further research? This relationship highlights the potential for interventions directed towards psychosocial support to have salutary effects upon gestational weight gain.

The role of gestational weight gain disorders in symptoms of maternal postpartum depression

OBJECTIVE

To examine the association of gestational weight gain (GWG), categorized according to 2009 IOM guidelines as adequate, inadequate, and excessive, with symptoms of mental disorders perceived by mothers after childbearing as anhedonia, anxiety, and depression, defined by the Edinburgh Postnatal Depression Scale (EPDS). Previous studies indicated that disorders related to GWG are associated with an increased risk of postpartum psychological distress.

METHODS

A prospective cohort study took place at the Policlinico Abano Terme, Italy, from May 2016 to November 2018.

RESULTS

The sample included 1268 healthy at term puerperae, 557 (43.9%) with adequate, 388 (30.6%) with inadequate, and 323 (25.5%) with excessive GWG. Mean EPDS scores were comparable among inadequate, adequate, and excessive GWG groups. However, mean factor scores for anhedonia and anxiety were significantly higher (P = 0.041 and P = 0.001, ANOVA) in mothers with excessive GWG. Conversely, factor scores for depression were significantly higher (P = 0.008, ANOVA) in mothers with inadequate GWG.

CONCLUSION

It was found that excessive GWG across an uncomplicated pregnancy is a warning sign of symptoms of anhedonia and anxiety, whereas inadequate GWG is a significant indicator of symptoms of depression. These relationships highlight the potential for interventions directed toward psychosocial support to have beneficial effects upon GWG.

Documenting and characterising gestational weight gain beliefs and experiences among Marshallese pregnant women in Arkansas: a protocol for a longitudinal mixed-methods study

INTRODUCTION

Arkansas has the largest population of Marshallese Pacific Islanders residing in the continental USA. The Marshallese have higher rates of obesity, type 2 diabetes, pre-term births, low birthweight babies, infant mortality, and inadequate or no prenatal care. Despite the high rates of cardiometabolic and maternal and child health disparities among Marshallese, there are no studies documenting gestational weight gain or perceptions about gestational weight gain among the Marshallese population residing in the USA.

METHODS AND ANALYSIS

This paper describes the protocol of a mixed-methods concurrent triangulation longitudinal study designed to understand gestational weight gain in Marshallese women. The mixed-methods design collects qualitative and quantitative data during simultaneous data collection events, at both first and third trimester, and then augments that data with postpartum data abstraction. Quantitative and qualitative data will be analysed separately and then synthesised during the interpretation phase.

ETHICS AND DISSEMINATION

The study used a community engaged approach approved by the University of Arkansas for Medical Sciences Institutional Review Board (#228023). The research team will disseminate results to study participants, research stakeholders (clinics, faith-based organisations and community-based organisation), the broader Marshallese community and fellow researchers. Results will be disseminated to study participants through a one-page summary that show the aggregated research results using plain language and infographics.

Pre-pregnancy body dissatisfaction and weight-related outcomes and behaviors during pregnancy

To examine relationships among pre-pregnancy body dissatisfaction (BD) and gestational weight gain (GWG), and related attitudes/behaviors. Pre-pregnancy BD was self-reported in early pregnancy. Weight-related attitudes/behaviors were self-reported and physical activity was objectively measured during pregnancy. Overall, 92% of the women reported BD, with 69% desiring a smaller pre-pregnancy size than their actual pre-pregnancy size. Ideal pre-pregnancy weight was 20.7 ± 28 pounds less than self-reported pre-pregnancy weight. Only weight-control strategies used at 35 weeks were associated with BD (p = 0.008). Pre-pregnancy BD may not predict risk for excess GWG and some weight-related issues during pregnancy.

DNA Methylation Reorganization of Skeletal Muscle-Specific Genes in Response to Gestational Obesity

The goals were to investigate in umbilical cord tissue if gestational obesity: (1) was associated with changes in DNA methylation of skeletal muscle-specific genes; (2) could modulate the co-methylation interactions among these genes. Additionally, we assessed the associations between DNA methylation levels and infant's variables at birth and at age 6. DNA methylation was measured in sixteen pregnant women [8-gestational obesity group; 8-control group] in umbilical cord using the Infinium Methylation EPIC Bead Chip microarray. Differentially methylated CpGs were identified with Beta Regression Models [false discovery rate (FDR) < 0.05 and an Odds Ratio > 1.5 or < 0.67]. DNA methylation interactions between CpGs of skeletal muscle-specific genes were studied using data from Pearson correlation matrices. In order to quantify the interactions within each network, the number of links was computed. This identification analysis reported 38 differential methylated CpGs within skeletal muscle-specific genes (comprising 4 categories: contractibility, structure, myokines, and myogenesis). Compared to control group, gestational obesity (1) promotes hypermethylation in highly methylated genes and hypomethylation in low methylated genes; (2) CpGs in regions close to transcription sites and with high CpG density are hypomethylated while regions distant to transcriptions sites and with low CpG density are hypermethylated; (3) diminishes the number of total interactions in the co-methylation network. Interestingly, the associations between infant's fasting glucose at age 6 and MYL6, MYH11, TNNT3, TPM2, CXCL2, and NCAM1 were still relevant after correcting for multiple testing. In conclusion, our study showed a complex interaction between gestational obesity and the epigenetic status of muscle-specific genes in umbilical cord tissue. Additionally, gestational obesity may alter the functional co-methylation connectivity of CpG within skeletal muscle-specific genes interactions, our results revealing an extensive reorganization of methylation in response to maternal overweight. Finally, changes in methylation levels of skeletal muscle specific genes may have persistent effects on the offspring of mothers with gestational obesity.

Maternal nutrition intervention focused on the adjustment of salt and sugar intake can improve pregnancy outcomes

Due to the increasing age of pregnant women, maternal nutrition management is becoming more important. Since pregnant women are more likely to consume sodium and sugars than nonpregnant women of the same age, we investigated whether maternal nutrition intervention focused on the adjustment of salt and sugar intake can help pregnancy outcome. This randomized controlled trial was performed on 142 pregnant women within 22 weeks of gestational age for at least 16 weeks until childbirth. Subjects were unequally assigned to the intervention group (n = 98) and the control group (n = 44). Dietary changes based on perceived taste preferences were evaluated by 24-hr dietary recall and food frequency questionnaires (FFQ) at pre- and postintervention. In the intervention group, while the intakes of energy, protein, and vitamins were maintained, the intakes of sodium (p < .001) and sugar from processed food (p < .05) were significantly reduced after the intervention. The decreases in salt and sugar consumption were more pronounced in the mothers who had a high preference for saltiness and sweetness. The mean neonatal birth weight of the intervention group was significantly greater than the weight of control group, (3,251.5 ± 402.2 g vs. 2,974.5 ± 294.8 g, p < .05). Through this study, nutrition intervention was found to be effective for the formation of healthy eating habits such as reduced salt and sugar intake in pregnant women especially with a high preference for saltiness and sweetness. Also, such specialized maternal nutrition intervention during pregnancy promotes the birth of healthy newborn babies of normal weight.

Dietary Protein Intake during Pregnancy Is Not Associated with Offspring Insulin Sensitivity during the First Two Years of Life

Literature describing a relationship between dietary protein intake during pregnancy and offspring insulin resistance are equivocal perhaps because of the lapse between maternal and offspring measurements (~9–40 years). Thus, we evaluated protein intake in healthy women [n = 182, mean ± SD; body mass index (BMI): 26.2 ± 4.2 kg/m²] in early pregnancy (8.4 ± 1.6 weeks, EP), late pregnancy (30.1 ± 0.4 weeks, LP), and averaged throughout pregnancy, and determined the relationship between protein intake and offspring homeostatic model assessment of insulin resistance (HOMA2-IR) at 12 (12mo) and 24 (24mo) months. EP protein (g·kg⁻¹·day⁻¹) did not associate with HOMA2-IR at 12mo (β = 0.153, p = 0.429) or 24mo (β = −0.349, p = 0.098). LP protein did not associate with HOMA2-IR at 12mo (β = 0.023, p = 0.916) or 24mo (β = −0.442, p = 0.085). Finally, average protein did not associate with HOMA2-IR at 12mo (β = 0.711, p = 0.05) or 24mo (β = −0.445, p = 0.294). Results remained unchanged after adjusting for plant protein intake quartiles during pregnancy, maternal BMI, and offspring sex and body fat percentage. Additionally, these relationships did not change after quartile analysis of average protein intake, even after considering offspring fasting time and HOMA2-IR outliers, and maternal under-reporters of energy intake. Protein intake during pregnancy is not associated with indirect measurements of insulin sensitivity in offspring during the first two years of life.

Immune epigenetic age in pregnancy and 1 year after birth: Associations with weight change

PROBLEM

Epigenetic age indices are markers of biological aging determined from DNA methylation patterns. Accelerated epigenetic age predicts morbidity and mortality. Women tend to demonstrate slower blood epigenetic aging compared to men, possibly due to female-specific hormones and reproductive milestones. Pregnancy and the post-partum period are critical reproductive periods that have not been studied yet with respect to epigenetic aging. The purpose of this paper was to examine whether pregnancy itself and an important pregnancy-related variable, changes in body mass index (BMI) between pregnancy and the post-partum period, are associated with epigenetic aging.

METHOD OF STUDY

A pilot sample of 35 women was recruited as part of the Healthy Babies Before Birth (HB3) project. Whole blood samples were collected at mid-pregnancy and 1 year post-partum. DNA methylation at both time points was assayed using Infinium 450K and EPIC chips. Epigenetic age indices were calculated using an online calculator.

RESULTS

Paired-sample t-tests were used to test differences in epigenetic age indices from pregnancy to 1 year after birth. Over this critical time span, women became younger with respect to phenotypic epigenetic age, GrimAge, DNAm PAI-1, and epigenetic age indices linked to aging-related shifts in immune cell populations, known as extrinsic epigenetic age. Post-partum BMI retention, but not prenatal BMI increases, predicted accelerated epigenetic aging.

CONCLUSION

Women appear to become younger from pregnancy to the post-partum period based on specific epigenetic age indices. Further, BMI at 1 year after birth that reflects weight retention predicted greater epigenetic aging during this period.

Obesity Status Affects the Relationship Between Protein Intake and Insulin Sensitivity in Late Pregnancy

The purpose of this study was to determine the associations between amount and type of dietary protein intake and insulin sensitivity in late pregnancy, in normal weight and overweight women (29.8 ± 0.2 weeks gestation, n = 173). A 100-g oral glucose tolerance test (OGTT) was administered following an overnight fast to estimate the metabolic clearance rate of glucose (MCR, mg·kg⁻¹·min⁻¹) using four different equations accounting for the availability of blood samples. Total (TP), animal (AP), and plant (PP) protein intakes were assessed using a 3-day food record. Two linear models with MCR as the response variable were fitted to the data to estimate the relationship of protein intake to insulin sensitivity either unadjusted or adjusted for early pregnancy body mass index (BMI) because of the potential of BMI to influence this relationship. There was a positive association between TP (β = 1.37, p = 0.002) and PP (β = 4.44, p < 0.001) intake in the last trimester of pregnancy and insulin sensitivity that weakened when accounting for early pregnancy BMI. However, there was no relationship between AP intake and insulin sensitivity (β = 0.95, p = 0.08). Therefore, early pregnancy BMI may be a better predictor of insulin sensitivity than dietary protein intake in late pregnancy.

Gestational Weight Gain Charts by Gestational Age and Body Mass Index for Chinese Women: A Population-Based Follow-up Study

Background

Establishment of an unbiased association between gestational weight gain (GWG) and perinatal health is urgently needed in China, which has the largest population in the world. Our study aimed to create weight-gain-for-gestational-age charts using early pregnancy body mass index (BMI) to present selected percentiles of GWG in China.

Methods

A population-based follow-up study was conducted based on the Maternal and Newborn Health Monitoring System, which recruited 132,835 pregnant women between October 2013 and September 2016 in 12 districts/counties of 6 provinces in China. Multilevel analyses and restricted cubic splines were performed to model the longitudinal repeated maternal weight gain measurements and obtain smoothed curves for GWG. The internal and external validation of each model was also assessed.

Results

To develop models of GWG, 34,288 women were included. Smoothed percentiles of GWG in the 3rd, 10th, 50th, 90th, and 97th percentiles were estimated for each week of gestation. The median figures for GWG were 15.0 kg, 14.4 kg, 13.5 kg, and 12.1 kg in underweight, normal weight, overweight, and obese women, respectively, at 40 weeks. Of all the weight measurements, more than 70% and 95% fell within the expected 1 to 2 standard deviations, respectively. To accomplish external validation of the models, 20,458 women were included. The specificities of measurements in the 5th, 10th, 15th, 25th, 75th, 85th, 90th, and 95th percentiles in four BMI categories were between 90% and 100%.

Conclusions

The population-based gestational weight gain Z-score charts performed well in providing guidance regarding expected gestational weight gain in Chinese women.

Prevalence and experiences of food insecurity among immigrant women connected to perinatal programs at a community-based organization in Edmonton, Canada

Purpose

The purpose of this paper is to investigate the prevalence of household food insecurity among immigrant women connected to perinatal programs offered through a community-based organization in Edmonton, and to explore their experiences in coping with food insecurity.

Design/methodology/approach

This study utilized a mixed methods research design. A community-based participatory research approach was used to engage health workers who were connected to immigrant women and families through the Multicultural Health Brokers Cooperative in Edmonton. Through the health workers a sample of 213 immigrant women connected to their perinatal programs completed the Household Food Security Survey. Following the survey, 17 women completed semi-structured interviews which were analyzed using content analysis.

Findings

The vast majority of women (94 percent (n=199)) lived in food insecure households, and 53 percent (n=112) in severely food insecure. In semi-structured interviews, women specifically described not having enough money to buy vegetables, fruit and meat, and perceiving a lack of control over foods they ate and offered to their families.

Practical implications

This study highlights the need for support to be provided to immigrant families for acquiring healthy food in Canada.

Originality/value

The mixed methods design with a decent sample of often underrepresented research participants highlights an area in need of further research and greater support.

Integrating Obstetrical Care and WIC Nutritional Services to Address Maternal Obesity and Postpartum Weight Retention

OBJECTIVE

This pilot study evaluated a cost neutral, integrated Special Supplemental Nutrition Program for Women Infants and Children (WIC) and obstetrical service model designed to prevent postpartum weight retention in obese women.

METHODS

A sample of women who received benefits from the Johns Hopkins (JH) WIC program and prenatal care from the JH Nutrition in Pregnancy Clinic, which provides obstetrical care for women with a BMI ≥ 30 kg/m², participated in the WICNIP randomized clinical trial. Intervention participants received enhanced nutrition services and education at five visits and during one phone call between delivery and 6 months postpartum. Control participants received standard WIC services. Weight data was collected for all participants at multiple time points: pre-pregnancy, delivery, and postpartum at 4, 6 weeks, 4, and 6 months. Maternal socio-demographic factors, obesity class and the number of education contacts received were also recorded.

RESULTS

Fifty-three African-American women were randomized into the intervention and control groups. Intervention participants retained significantly less gestational weight gain than control participants (3.0 ± 11.8 vs. 12.6 ± 20.4, p < 0.05). In both groups, participants with Class III obesity retained significantly less weight than participants in Classes I and II (p = 0.02).

CONCLUSIONS FOR PRACTICE

An integrated WIC and obstetrical service model is feasible and can limit postpartum weight retention in obese women. Weight retention at 6 months postpartum between intervention and control participants was statistically significant. Further research should explore targeted interventions by obesity class to address weight retention for low-income, African American women who participate in WIC.

Circulating sex hormone binding globulin: An integrating biomarker for an adverse cardio-metabolic profile in obese pregnant women

Sex hormone-binding globulin (SHBG) negatively associates with pre-gestational body mass index (BMI) and gestational weight gain. The link with other cardio-metabolic risk factors in pregnant women is poorly understood. Our aim was to study the association of SHBG levels with common cardio-metabolic risk parameters in pregnant woman.

Serum SHBG was quantified in 291 Caucasian pregnant women (142 with normal weight, 42 with pregestational obesity, 50 with gestational obesity and 57 with pregestational plus gestational obesity) with uncomplicated pregnancies and parturition. Cardio-metabolic [C-reactive protein (CRP), blood pressure (BP), glycosylated hemoglobin (HbAc1), glucose, C-peptide, insulin, triglycerides and high molecular weight (HMW) adiponectin], and endocrine [testosterone and estradiol] parameters were also assessed.

SHBG was negatively correlated with BMI, but also with CRP, BP, HbAc1, pre and post-load glucose, C-peptide, HOMA-IR, triglycerides; and positively with HMW adiponectin (all p<0.01 to p<0.0001). These associations were more robust in women with pregestational plus gestational obesity, who had lower SHBG, in comparison to normal-weight women (p<0.0001). In multivariate analyses in women with pregestational plus gestational obesity SHBG showed independent associations with CRP (β = −0.352, p = 0.03, R² = 8.0%), DBP (β = −0.353, p = 0.03, R² = 7.0%) and SBP (β = −0.333, p = 0.04, R² = 6.0%) independently of BMI and metabolic and endocrine parameters.

SHBG is decreased in pregnant women with pregestational plus gestational obesity in association with common cardio-metabolic parameters. SHBG could represent an integrating biomarker for an adverse cardio-metabolic profile in pregnant women with pregestational plus gestational obesity.

Prepregnancy Body Mass Index shift across gestation: primary evidence of an association with eating disorders

Objective: Previous studies indicated that gestational weight gain-related disorders share many similarities with feeding and eating disorders (EDs).Design: To examine the association of prepregnancy Body Mass Index (BMI), defined according to 2009 Institute of Medicine (IOM), and its shift across gestation with symptoms of feeding and EDs, defined by EDE-Q.Setting: This prospective cohort study took place at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy, from Jannuary 2015 to October 2015.Population and sample: The sample included 655 healthy at term puerperae.Main outcomes measures: We correlated gestational BMI in different women categories to EDE-Q Global score and Restrain, Eating concern, Shape concern, and Weight concern subscales, by Spearman's correlation test.Results: Among 655 women, 59 (9.0%) were categorized as underweight, 463 (70.7%) normal weight, 98 (15.0%) overweight, and 35 (5.3%) as obese in prepregnancy period. At the end of gestation, underweight women category disappeared, normal weight women lightened to one third, overweight women tripled, and obese women doubled. At the same time, EDE-Q global scores increased from normal weight (0.25 ± 0.41), to overweight (0.47 ± 0.58), and to obese (0.72 ± 0.70) puerperae. In addition, EDE-Q global scores were significantly correlated with gestational BMI increase in Global score (rho = 0.326; p < .001) and in the four subscales: Restrain (rho = 0.161; p < .001), Eating concern (rho = 0.193; p < .001), Shape concern (rho = 0.335; p < .001), and Weight concern (rho = 0.365; p < .001), respectively.Conclusions: It was found that the shift of woman BMI across an uncomplicated pregnancy is a warning indicator of unhealthy eating and feeding symptoms.

Association between women's perceived ideal gestational weight gain during pregnancy and pregnancy outcomes

We aimed to clarify which beliefs motivate women to control their weight during pregnancy and how such values influence pregnancy outcomes. Using a questionnaire administered during mid- to late- pregnancy in a hospital-based prospective cohort study, we explored women’s perceived ideal GWG and their reasons for having this ideal. Using multivariate regression, we evaluated the association between women’s perceived ideal GWG and pregnancy outcomes. Among 1,691 normal and underweight women, the most common reason women thought avoiding excessive weight gain was important was “for ease of delivery and/or her health and well-being”. 912 (54%) women wished to maintain their GWG below 12 kg, the upper limit recommended by the Japanese governmental guidelines, and had a lower actual GWG compared to those who had less stringent notions of GWG. Compared to women whose perceived ideal GWG was 12 kg, those who considered their perceived limit to be lower had infants with lower birthweight on average despite no significant reduction in cesarean delivery rate or post-partum body weight retention. Our findings suggest that women who believe they should limit their weight gain to an amount lower than the upper limit of current guidelines succeeded in gaining significantly less weight but received no additional benefit.

Attenuating Pregnancy Weight Gain-What Works and Why: A Systematic Review and Meta-Analysis

Excessive maternal gestational weight gain (GWG) contributes to generational obesity. Our aim was to explore efficacy and intervention characteristics (trimester, duration, frequency, intensity, and delivery method) of interventions to prevent excessive GWG. CINAHL, Cochrane, EMBASE, LILACS, MEDLINE, PsycINFO, and Scopus were searched up to May 2018 (no date or language restrictions). Keywords and MeSH terms for diet, GWG, intervention, lifestyle, maternal, physical activity, and pregnancy were used to locate randomized-controlled trials (RCTs). The Cochrane Collaboration tool for assessing risk of bias was applied. Eighty-nine RCTs were included. Meta-analysis (60 trials) estimated that women in diet only (WMD: -3.27; 95% CI: -4.96, -1.58, p < 0.01), physical activity (PA) (WMD: -1.02; 95% CI: -1.56, -0.49, p < 0.01), and lifestyle interventions (combining diet and PA) (WMD: -0.84; 95% CI: -1.29, -0.39, p < 0.01) gained significantly less weight than controls. The three eHealth interventions favored neither intervention nor control (WMD: -1.06; 95% CI: -4.13, 2.00, p = 0.50). Meta-regression demonstrated no optimal duration, frequency, intensity, setting, or diet type. Traditional face to face delivery of weight management interventions during pregnancy can be successful. Delivery via eHealth has potential to extend its reach to younger women but needs further evaluation of its success.

Trends in Obesity and Risk of Cardiovascular Disease

Purpose of review

The obesity epidemic is a global health crisis of staggering proportion. Excess body weight is a major risk factor for the development of cardiovascular disease (CVD). We review temporal trends in obesity rates, pertinent pathophysiology to understand mechanisms of disease, and treatment strategies in the context of reducing cardiovascular risk.

Recent findings

The prevalence of obesity is increasing in recent decades and is driven by a complex interplay of economic, environmental, and biological factors. In developed countries, changes in foodintake, such as increased consumption of energy-dense and added sugar have contributed significantly to weight gain. Single nucleotide variations in genes and alterations in the gut microbiome have been associated with the obese phenotype. The description of an obesity paradox in patients with CVD may have several explanations, including limitations of body mass index (BMI) to assess adiposity, selection bias, and lead-time bias with earlier onset of disease. Evidence-based treatments for weight loss include lifestyle intervention, pharmacotherapy, and bariatric surgery. Data on the long-term effects of these therapies on cardiovascular risk are limited.

Summary

Overweight and obesity are associated with increased cardiovascular morbidity and mortality over the lifespan. Despite our increasing understanding of biological and environmental drivers of obesity, more work is needed in developing effective prevention strategies and implementation of evidence-based treatments to promote cardiovascular health and reduce cardiovascular risk. Ultimately, efforts to prevent and postpone cardiovascular morbidity should include focus on maintenance of normal BMI (primordial prevention) for a longer and healthier life, free of CVD.

Serum 25-hydroxyvitamin D and cardiovascular disease risk factors in women with excessive weight gain during pregnancy and in their offspring at age 5-6 years

BACKGROUND/OBJECTIVE

Low 25-hydroxyvitamin D levels [25(OH)D] may increase the risk for cardiovascular disease (CVD). In pregnant women excessive weight gain and 25(OH)D deficiency are common complications and both could have deleterious consequences on their children. We aimed to study the relationship between serum 25(OH)D and CVD risk factors in pregnant women and in their offspring at school age.

SUBJECTS/METHODS

Fasting serum 25(OH)D and its bioavailable fraction were quantified in 310 healthy pregnant women [with adequate (n = 113), insufficient (n = 113) and excessive (n = 84) weight gain]. A follow-up at 5-6 years was performed in sixty-six children born of these mothers. Lipids, insulin, glucose, and high-sensitivity C-reactive protein (hsCRP) were measured in all subjects. Children's carotid intima-media thickness (cIMT) together with visceral and intra-abdominal fat were measured by ultrasonography.

RESULTS

Lower maternal 25(OH)D concentrations were associated with lower maternal age, and higher body mass index, triglycerides and hsCRP (all p < 0.05). In women with excessive weight gain during gestation, serum 25(OH)D concentrations showed independent associations with maternal hsCRP (β = -0.283 p = 0.03) and triglycerides (β = -0.436, p = 0.005). Maternal serum 25(OH)D concentrations were also independently associated with cIMT (β = -0.288, p = 0.04), visceral fat (β = -0.281, p = 0.01) and intra-abdominal fat (β = -0.248, p = 0.01) in their children at 5-6 years.

CONCLUSIONS

Lower serum 25(OH)D concentrations were related to CVD risk factors in pregnant woman and in their offspring. The cardiometabolic consequences of low 25(OH)D concentrations during pregnancy could be aggravated by excessive weight gain during gestation.

Provider Advice and Women's Intentions to Meet Weight Gain, Physical Activity, and Nutrition Guidelines During Pregnancy

OBJECTIVES

To determine the prevalence and accuracy of patient-reported provider advice on weight gain, physical activity, and nutrition during prenatal visits and to examine the associations of provider advice with women's behavioral intentions toward weight gain, physical activity, and nutrition.

METHODS

A mixed-methods study design was used to assess patient-report of provider advice and health intentions in women between 20 and 30 weeks gestation (n = 188). Bivariate analyses examined patient-reported provider advice on weight gain, physical activity, and nutrition with women's behavioral intentions. Linear and logistic regression models examined associations of provider weight gain recommendations with women's intended weight gain.

RESULTS

Approximately 52 % of women reported provider advice on weight gain, 63 % on physical activity, and 56 % on nutrition. Of those who reported weight gain advice, 79 % cited provider recommendations within the Institute of Medicine guidelines, 9 % below, and 11 % above. Patient-report of provider advice on physical activity and nutrition were consistent with guidelines, but limited in scope. Provider advice (yes/no) was significantly associated with women's intentions to meet physical activity (p = 0.01) and nutrition (p = 0.02), but not weight gain guidelines (p = 0.86). Provider recommended weight gain (pounds) was significantly associated with women's intended weight gain in linear and logistic regression models.

CONCLUSIONS FOR PRACTICE

A large percentage of women report receiving no advice from providers on weight gain, physical activity or nutrition during pregnancy. Of those who receive advice, most report recommendations consistent with current guidelines. Provider advice was associated with women's weight gain, physical activity, and nutrition intentions in pregnancy.

Effect of dietary counseling on preventing excessive weight gain during pregnancy

OBJECTIVES

Excessive gestational weight gain (EGWG) is associated with short- and long-term health problems among mothers and their offspring. The aim of this study was to assess the effect of dietary counseling on EGWG.

STUDY DESIGN

Randomized controlled intervention trial.

METHODS

The study was conducted at the antenatal care (ANC) clinic, Center for Social and Preventive Medicine, Pediatrics Hospital, Cairo University, during the period from July 2015 to April 2016. A total of 200 primigravidae aged between 20 and 30 years were included and randomized into intervention and control groups. Based on data analysis from phase 1, nutritional practices of the studied participants were identified and tailored nutrition counseling sessions designed. Follow-up of the studied participants throughout ANC visits was done to enforce the healthy dietary intake and encourage weight gain according to the recommendations to avoid EGWG.

RESULTS

The intervention resulted in a significantly higher proportion of women in the intervention group who gained gestational weight within the Institute of Medicine recommendations compared to women in the control group (42.7% vs 13.9%, respectively) (P-value <0.001); this was detected between the 25th and 35th weeks of gestation. Dietary counseling had significantly improved the frequency of consumption of different food items and knowledge, attitude, and practice mean scores of the intervention group in comparison with the control group (P-value <0.001).

CONCLUSIONS

The results of the present study demonstrated that dietary counseling given to pregnant women reduced the proportion of EGWG and improved dietary practices. There is a strong need for effective intervention strategies targeting EGWG to prevent adverse pregnancy outcomes.

Trajectory modeling of gestational weight: A functional principal component analysis approach

Suboptimal gestational weight gain (GWG), which is linked to increased risk of adverse outcomes for a pregnant woman and her infant, is prevalent. In the study of a large cohort of Canadian pregnant women, our goals are to estimate the individual weight growth trajectory using sparsely collected bodyweight data, and to identify the factors affecting the weight change during pregnancy, such as prepregnancy body mass index (BMI), dietary intakes and physical activity. The first goal was achieved through functional principal component analysis (FPCA) by conditional expectation. For the second goal, we used linear regression with the total weight gain as the response variable. The trajectory modeling through FPCA had a significantly smaller root mean square error (RMSE) and improved adaptability than the classic nonlinear mixed-effect models, demonstrating a novel tool that can be used to facilitate real time monitoring and interventions of GWG. Our regression analysis showed that prepregnancy BMI had a high predictive value for the weight changes during pregnancy, which agrees with the published weight gain guideline.

Gestational Weight Gain and Pre-pregnancy Body Mass Index Associated With Second-Generation Antipsychotic Drug Use During Pregnancy

BACKGROUND

Obesity during pregnancy is the most common high-risk obstetric condition, resulting in increased rates of adverse maternal and neonatal outcomes. Individuals with psychiatric disorders have a higher risk of obesity than the general population, but data regarding implications of obesity in women with psychiatric disorders are sparse.

OBJECTIVE

The objective of this study was to assess pre-pregnancy weights and gestational weight gain in women who were exposed to second-generation antipsychotics (SGAs) during pregnancy compared to controls.

METHODS

We assessed pre-pregnancy weights and gestational weight gain from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics for patients exposed to SGAs and controls unexposed to these medicines during pregnancy. Both groups experienced similar psychiatric morbidity.

RESULTS

A total of 403 participants had evaluable data for these analyses (N = 279 exposed to SGAs; N = 124 controls). The mean pre-pregnancy weight, body mass index (BMI), and likelihood to begin pregnancy with an obese BMI were significantly higher in the exposed group compared to controls (p = 0.0003, p < 0.0001, and p < 0.0001 respectively), as were the mean weight and BMI at delivery (p < 0.0001). The mean weight gain did not differ significantly between groups. Across pre-pregnancy BMI categories, both groups gained more than the recommended amount of weight during pregnancy.

CONCLUSION

We found that women exposed to SGAs began pregnancy with higher BMIs than controls. Both exposed and unexposed groups experienced similar weight gain during pregnancy. Strategies are needed to prevent excessive gestational weight gain and to reduce pre-pregnancy obesity in women with psychiatric disorders, especially those treated with SGAs.

Dysregulation of Placental miRNA in Maternal Obesity Is Associated With Pre- and Postnatal Growth

CONTEXT

Human placenta exhibits a specific microRNA (miRNA) expression pattern. Some of these miRNAs are dysregulated in pregnancy disorders such as preeclampsia and intrauterine growth restriction and are potential biomarkers for these pathologies.

OBJECTIVE

To study the placental miRNA profile in pregnant women with pregestational overweight/obesity (preOB) or gestational obesity (gestOB) and explore the associations between placental miRNAs dysregulated in maternal obesity and prenatal and postnatal growth.

METHODS

TaqMan Low Density Arrays and real-time polymerase chain reaction were used to profile the placental miRNAs in 70 pregnant women (20 preOB, 25 gestOB, and 25 control). Placentas and newborns were weighed at delivery, and infants were weighed at 1, 4, and 12 months of age.

RESULTS

Eight miRNAs were decreased in placentas from preOB or gestOB (miR-100, miR-1269, miR-1285, miR-181, miR-185, miR-214, miR-296, and miR-487) (all P < 0.05). Among them, miR-100, miR-1285, miR-296, and miR-487 were associated with maternal metabolic parameters (all P < 0.05) and were predictors of lower birth weight (all P < 0.05; R2 > 30%) and increased postnatal weight gain (all P < 0.05; R2 > 20%). In silico analysis showed that these miRNAs were related to cell proliferation and insulin signaling pathways. miR-296 was also present in plasma samples and associated with placental expression and prenatal and postnatal growth parameters (all P < 0.05).

CONCLUSIONS

We identified a specific placental miRNA profile in maternal obesity. Placental miRNAs dysregulated in maternal obesity may be involved in mediation of growth-promoting effects of maternal obesity on offspring and could be used as early markers of prenatal and postnatal growth.

Thin mother, obese child? A review of early risk factors for obesity in offspring

PURPOSE OF REVIEW

The huge percentages of persons with obesity in many countries constitute a public health crisis. The severe consequences of obesity for physical health and emotional wellbeing already emerge in childhood. Therefore, the acknowledgment of early risk factors is essential to provide recommendations for prevention strategies. This review outlines the current state of research concerning early risk factors for obesity, that is, factors that even contribute to later obesity of the offspring during gestation. In this regard, this review specifically addresses the link between restricted eating behavior of the mother and obesity in her offspring. We systematically searched for articles in PsychINFO, PsychINDEX, MEDLINE, PubMed, MEDPILOT, and Web of Science, and we identified additional studies in bibliographies.

RECENT FINDINGS

Although some risk factors (e.g., short period of breastfeeding, gestational diabetes, and high maternal BMI) have a vast evidence base, others (e.g., restricted eating behavior and second-hand smoking) are insufficiently studied.

SUMMARY

Physical activity and diet programs in pregnancy can reduce not only the occurrence of gestational diabetes, but also the risk of inappropriate weight gain. As smoking during pregnancy and inappropriate eating behavior are associated with lower education, psychoeducation, for instance in sex education classes, could be easily conceivable.

Pregnancy weight gain by gestational age and BMI in Sweden: a population-based cohort study

BACKGROUND

Pregnancy weight-gain z score charts have recently been proposed as a new tool for classifying gestational weight gain and establishing the link between weight gain and adverse maternal and infant outcomes. However, existing charts are few in number, were based on small sample sizes, and were not population based.

OBJECTIVE

We created population-based pregnancy weight-gain-for-gestational-age z score charts for Swedish women who were stratified by early pregnancy body mass index (BMI).

DESIGN

Serial prenatal electronic medical records were obtained from women who were receiving obstetrical care in the Swedish counties of Gotland and Stockholm. The study population was restricted to nonanomalous, singleton, term pregnancies with no prepregnancy hypertension or diabetes. A multilevel linear regression was used to express the repeated weight-gain measurements as a function of gestational age in underweight, normal-weight, overweight, and obese class I-III women. Observed weight-gain ranges were contrasted with current Institute of Medicine (IOM) pregnancy weight-gain recommendations.

RESULTS

A total of 711,615 serial prenatal weight measurements from 141,767 pregnant women were included. The smoothed means, SDs, and selected percentiles (3rd, 10th, 50th, 90th, and 97th) of weight gain were estimated for each week of gestation. The total weight gain and rate of weight gain decreased with increasing prepregnancy BMI. In all BMI categories, the observed range of pregnancy weight gain was considerably broader than the range currently recommended by the IOM.

CONCLUSIONS

The presented population-based pregnancy weight-gain charts can be used to express maternal weight gain as gestational age-standardized z scores with early pregnancy BMI taken into consideration. The z scores can be used to obtain a better understanding of the relation between pregnancy weight gain and maternal and infant health complications.

African American and White women׳s perceptions of weight gain, physical activity, and nutrition during pregnancy

OBJECTIVE

To describe African American and White women's perceptions of weight gain, physical activity, and nutrition during pregnancy and to explore differences in perceptions by race.

DESIGN

Qualitative interview study.

SETTING

Two Ob/Gyn clinics in South Carolina, USA.

PARTICIPANTS

Thirty pregnant women (15 African American, 15 White) between 20 and 30 weeks gestation, equally represented across pre-pregnancy BMI categories (10 normal weight, 10 overweight, and 10 obese).

FINDINGS

White women more frequently described intentions to meet weight gain, physical activity, and dietary guidelines in pregnancy than African American women. African American women were more concerned with inadequate weight gain while White women more commonly expressed concerns about excessive weight gain. More White women discussed the importance of physical activity for weight management. Regardless of race, few women described risks of excessive weight gain or benefits of physical activity as it relates to the baby's health. The primary cited barrier of healthy eating was the high cost of fresh produce.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Several knowledge gaps as well as race differences were identified in women's perceptions and intentions toward weight gain, physical activity, and nutrition during pregnancy. Future interventions should seek to educate women about common misperceptions. It may be necessary to culturally tailor gestational weight gain interventions to optimise health outcomes.

Association of Provider Advice and Pregnancy Weight Gain in a Predominantly Hispanic Population

OBJECTIVES

This study sought to determine whether women's report of gestational weight gain (GWG) advice from a health care provider is consistent with the Institute of Medicine (IOM) guidelines and the association between provider advice and women's weight gain during pregnancy.

METHODS

Data came from the 2007 Los Angeles Mommy and Baby study (n = 3,402). The 1990 IOM GWG guidelines were used to define whether the provider's advice on weight gain and women's weight gain were below, within, or above the guidelines.

RESULTS

Approximately 4 months after delivery, 18.8% of the women reported having not discussed weight gain with any health care providers during pregnancy. Among those who reported such discussions, 42% reported receiving weight gain advice from a health care provider within IOM guidelines, 16.5% below guidelines, and 10% above. An additional 13.5% reported the discussion but did not report the recommended weight gain amount. Compared with women who reported provider advice on weight gain within guidelines, women who reported advice below guidelines were 1.7 times (95% confidence interval [CI], 1.3-2.2) more likely to gain less than the IOM recommended amount. Women who reported provider advice above IOM guidelines were 2.0 times (95% CI, 1.4-2.9) more likely to exceed guidelines.

CONCLUSIONS

There is a need for more women to receive advice consistent with the IOM GWG guidelines from their prenatal care providers. Intervention strategies are needed to educate providers about IOM guidelines and how to counsel on GWG.

Pregnant women's perceptions of weight gain, physical activity, and nutrition using Theory of Planned Behavior constructs

A better understanding of women's perceptions of weight gain and related behaviors during pregnancy is necessary to inform behavioral interventions. We used the Theory of Planned Behavior (TPB) to examine pregnant women's perceptions and intentions toward weight gain, physical activity (PA), and nutrition using a mixed methods study design. Women between 20 and 30 weeks gestation (n = 189) were recruited to complete an Internet-based survey. Salient beliefs toward weight gain, PA, and nutrition were captured through open-ended responses and content analyzed into themes. TPB constructs (attitude, subjective norm, perceived behavioral control, intentions) were examined using Pearson correlations and hierarchical linear regression models. Salient beliefs were consistent with the existing literature in non-pregnant populations, with the addition of many pregnancy-specific beliefs. TPB constructs accounted for 23-39 % of the variance in weight gain, PA, and nutrition intentions, and made varying contributions across outcomes. The TPB is a useful framework for examining women's weight-related intentions during pregnancy. Study implications for intervention development are discussed.

Preventing excessive weight gain during pregnancy and promoting postpartum weight loss: a pilot lifestyle intervention for overweight and obese African American women

To test the feasibility and acceptability of a theory-based lifestyle intervention designed to prevent excessive weight gain during pregnancy and promote weight loss in the early postpartum period in overweight and obese African American women. Sixteen pregnant women (≤18 weeks gestation) were recruited from prenatal clinics in Columbia, South Carolina in 2011 and assigned to a lifestyle intervention program. The intervention, guided by formative research, consisted of an individual counseling session followed by eight group sessions alternated with telephone counseling contacts that continued through 36 weeks of gestation. At 6-8 weeks postpartum, participants received a home visit and up to three counseling calls through week 12. Medical charts were reviewed for 38 contemporary controls who met the same inclusion criteria and attended the same prenatal clinics. Compared to controls, study participants gained less total weight, had a smaller weekly rate of weight gain across the 2nd and 3rd trimesters (0.89 vs. 0.96 lbs), and were less likely to exceed weight gain recommendations (56.3 vs. 65.8 %). At 12 weeks postpartum, study participants retained 2.6 lbs from their prepregnancy weight, half of study participants were at their prepregnancy weight or lower, and only 35 % retained ≥5 lbs. The intervention also demonstrated success in promoting physical activity and reducing caloric intake, and was well-received by participants. The initial results were promising. The lessons learned can help inform future studies. The efficacy of our intervention will be tested in a large randomized controlled trial.

Obesity and anxiety during pregnancy and postpartum: A systematic review

BACKGROUND

Obesity and anxiety during the perinatal period are common and associated with poor health outcomes for the mother and the child. Despite the well-documented health risks of both pregnancy obesity and anxiety, associations between the two have rarely been explored. With this review we aim to provide a systematic overview of the current state of evidence concerning associations between ante- and postnatal anxiety and pregnancy obesity, excessive gestational weight gain, and postpartum weight retention.

METHODS

We conducted a systematic literature search in PubMed, Web of Science, and PsychINFO.

RESULTS

13 Records matched our inclusion criteria. Five out of seven studies focusing on pregnancy obesity and anxiety suggest a positive association with ante- or postnatal anxiety. Surprisingly, no study examined anxiety disorders according to DSM and it remains unknown whether anxiety symptomatology reaches clinical relevance. Results from a small number of life-style intervention studies (n=3) suggest that interventions could benefit from a stronger focus on mental health. There were not enough studies on associations between excessive gestational weight gain (n=2) or postpartum weight retention (n=3) and anxiety making it difficult to draw conclusions about possible associations.

LIMITATION

The number of included studies is rather small and studies were included irrespective of the study quality which might limit the generalizability of the results.

CONCLUSIONS

The majority of the included studies suggest that obese pregnant women might constitute a subgroup that is especially vulnerable for comorbid anxiety and in need of targeted psychological support. However, further high-quality studies, particularly including anxiety disorders, are needed.

The effect of maternal obesity on the offspring

Maternal obesity is inextricably linked to adverse health outcomes for the mother and her children. The peripartum period is a critical period of risk. In this chapter, we examine the importance of maternal prepregnancy weight status, gestational weight gain, breastfeeding, and postpartum weight loss in relation to subsequent risk for maternal obesity and obesity in the offspring. Promoting optimal maternal weight during the preconception, pregnancy, and postpartum periods will provide lifelong benefits for maternal health and the health of her progeny.

Exercise during pregnancy and its association with gestational weight gain

We examined the association between exercise during pregnancy and meeting gestational weight gain recommendations. Data came from the 2009 South Carolina Pregnancy Risk Assessment Monitoring System (n = 856). Women reported their participation in exercise/sports activities before and during pregnancy, including the number of months and types of exercise. We developed an exercise index (EI), the product of the number of months spent in exercise and average metabolic equivalents for specific exercise. The 2009 Institute of Medicine's guideline was used to categorize gestational weight gain into three classes: inadequate, adequate, and excessive. Multinomial logistic regression models were used to adjust for confounders. Over 46 % of women exceeded the recommended weight gain during pregnancy. Nearly one third (31.9 %) of women reported exercising ≥3 times a week at any time during pregnancy. Compared to women who did not report this level of exercise during pregnancy, exercising women were more likely to meet gestational weight gain recommendations (32.7 vs. 18.7 %) and had a lower odds of excessive gestational weight gain [adjusted odds ratio (AOR) 0.43, 95 % confidence interval 0.24-0.78]. Women with an EI above the median value of those women who exercised or women who exercised ≥3 times a week for 6-9 months during pregnancy had lower odds of excessive gestational weight gain (AOR for EI 0.20, 0.08-0.49; AOR for months 0.26, 0.12-0.56, respectively). Our findings support the need to promote or increase exercise during pregnancy to reduce the high proportion of women who are gaining excessive weight.

How much weight are women gaining during pregnancy? An Italian cohort study

INTRODUCTION

The 2009 Institute of Medicine (IOM) guidelines define adequate gestational weight gain (GWG) in the attempt to prevent maternal and neonatal adverse outcomes. The aim of this study was to assess whether the IOM guidelines are met in pregnant women with different pre-gestational body mass index (BMI).

METHODS

The study included 230 pregnant women recruited at the University Hospital of Pisa (Italy) at their screening visit (24-28 weeks of gestation) for gestational diabetes (GDM). GWG was determined at screening time and before delivery to be compared with GWG recommended by IOM for each pre-pregnancy BMI category.

RESULTS

A total of 48% of women had a GWG exceeding IOM recommendations. The prevalence of GWG excess was higher in over-weight (OW, 63.2%) and obese (OB, 63.8%) women as compared to normal-weight (NW, 27.7%; p < 0.0001) women. The upper limit of the recommended IOM weight gain range was already exceeded at screening time in 15.5% of women. The percentage increased 27% and 18% in OW and OB, respectively, compared with 1.5% in NW (p < 0.001).

CONCLUSION

About half of pregnant women had a GWG greater than the IOM recommended. GWG excess is particularly evident in OW and OB women.

Study protocol: differential effects of diet and physical activity based interventions in pregnancy on maternal and fetal outcomes--individual patient data (IPD) meta-analysis and health economic evaluation

BACKGROUND

Pregnant women who gain excess weight are at risk of complications during pregnancy and in the long term. Interventions based on diet and physical activity minimise gestational weight gain with varied effect on clinical outcomes. The effect of interventions on varied groups of women based on body mass index, age, ethnicity, socioeconomic status, parity, and underlying medical conditions is not clear. Our individual patient data (IPD) meta-analysis of randomised trials will assess the differential effect of diet- and physical activity-based interventions on maternal weight gain and pregnancy outcomes in clinically relevant subgroups of women.

METHODS/DESIGN

Randomised trials on diet and physical activity in pregnancy will be identified by searching the following databases: MEDLINE, EMBASE, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database. Primary researchers of the identified trials are invited to join the International Weight Management in Pregnancy Collaborative Network and share their individual patient data. We will reanalyse each study separately and confirm the findings with the original authors. Then, for each intervention type and outcome, we will perform as appropriate either a one-step or a two-step IPD meta-analysis to obtain summary estimates of effects and 95% confidence intervals, for all women combined and for each subgroup of interest. The primary outcomes are gestational weight gain and composite adverse maternal and fetal outcomes. The difference in effects between subgroups will be estimated and between-study heterogeneity suitably quantified and explored. The potential for publication bias and availability bias in the IPD obtained will be investigated. We will conduct a model-based economic evaluation to assess the cost effectiveness of the interventions to manage weight gain in pregnancy and undertake a value of information analysis to inform future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2013: CRD42013003804.