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

OBJECTIVE

Stay-at-home orders in response to the coronavirus disease 2019 (COVID-19) pandemic have forced abrupt changes to daily routines. This study assessed lifestyle changes across different BMI classifications in response to the global pandemic.

METHODS

The online survey targeting adults was distributed in April 2020 and collected information on dietary behaviors, physical activity, and mental health. All questions were presented as "before" and "since" the COVID-19 pandemic.

RESULTS

In total, 7,753 participants were included; 32.2% of the sample were individuals with normal weight, 32.1% had overweight, and 34.0% had obesity. During the pandemic, overall scores for healthy eating increased (P < 0.001), owing to less eating out and increased cooking (P < 0.001). Sedentary leisure behaviors increased, while time spent in physical activity (absolute time and intensity adjusted) declined (P < 0.001). Anxiety scores increased 8.78 ± 0.21 during the pandemic, and the magnitude of increase was significantly greater in people with obesity (P ≤ 0.01). Weight gain was reported in 27.5% of the total sample compared with 33.4% in participants with obesity.

CONCLUSIONS

The COVID-19 pandemic has produced significant health effects, well beyond the virus itself. Government mandates together with fear of contracting the virus have significantly impacted lifestyle behaviors alongside declines in mental health. These deleterious impacts have disproportionally affected individuals with obesity.

Effectiveness of SmartMoms, a Novel eHealth Intervention for Management of Gestational Weight Gain: Randomized Controlled Pilot Trial

BACKGROUND

Two-thirds of pregnant women exceed gestational weight gain (GWG) recommendations. Because excess GWG is associated with adverse outcomes for mother and child, development of scalable and cost-effective approaches to deliver intensive lifestyle programs during pregnancy is urgent.

OBJECTIVE

The aim of this study was to decrease the proportion of women who exceed the Institute of Medicine (IOM) 2009 GWG guidelines.

METHODS

In a parallel-arm randomized controlled trial, 54 pregnant women (age 18-40 years) who were overweight (n=25) or obese (n=29) were enrolled to test whether an intensive lifestyle intervention (called SmartMoms) decreased the proportion of women with excess GWG, defined as exceeding the 2009 IOM guidelines, compared to no intervention (usual care group). The SmartMoms intervention was delivered through mobile phone (remote group) or in a traditional in-person, clinic-based setting (in-person group), and included a personalized dietary intake prescription, self-monitoring weight against a personalized weight graph, activity tracking with a pedometer, receipt of health information, and continuous personalized feedback from counselors.

RESULTS

A significantly smaller proportion of women exceeded the IOM 2009 GWG guidelines in the SmartMoms intervention groups (in-person: 56%, 10/18; remote: 58%, 11/19) compared to usual care (85%, 11/13; P=.02). The remote intervention was a lower cost to participants (mean US $97, SD $6 vs mean US $347, SD $40 per participant; P<.001) and clinics (US $215 vs US $419 per participant) and with increased intervention adherence (76.5% vs 60.8%; P=.049).

CONCLUSIONS

An intensive lifestyle intervention for GWG can be effectively delivered via a mobile phone, which is both cost-effective and scalable.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01610752; https://clinicaltrials.gov/ct2/show/NCT01610752 (Archived by WebCite at http://www.webcitation.org/6sarNB4iW).

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

PURPOSE

The spread of COVID-19 and the associated stay-at-home orders and shutdowns of gyms and fitness centers have drastically influenced health behaviors leading to widespread reductions in physical activity (PA). The recent Call to Action from the American College of Sports Medicine has promoted "innovative strategies to promote PA during the COVID-19 pandemic." We aimed to identify individual-level factors that protected against declines in PA levels amid the COVID-19 restrictions.

METHODS

We used the Pennington Biomedical COVID-19 Health Behaviors Survey for our analyses and used mixed-effect linear and generalized linear models to estimate the effects of individual-level factors on changes in PA levels during the COVID-19 restrictions.

RESULTS

Participants (n = 4376) provided information on PA behaviors before and during the COVID-19 shutdown. Overall, PA levels declined by a mean ± SD of 112 ± 1460 MET·min·wk-1 during the COVID-19 shutdown; however, changes in PA were heterogeneous, with 55% of the participants reporting increases in or maintenance of PA during that time. Several social and demographic factors were significantly related to declines in PA, including high prepandemic PA levels, living alone (difference = 118 MET·min·wk-1), low household income (difference between the highest and the lowest income group = 363 MET·min·wk-1), COVID-19-related changes in income (difference = 110 MET·min·wk-1), and loss of employment (difference = 168 MET·min·wk-1). The substitution of prepandemic gym attendance with the purchase and use of home exercise equipment or exercise through virtual fitness platforms promoted increases in PA during the COVID-19 shutdown.

CONCLUSIONS

While promoting PA through the COVID-19 pandemic, it is important to consider demographic factors, which greatly influence health behaviors and implementation of, and access to, replacement behaviors. The promotion of such strategies could help maintain PA levels during potential future stay-at-home orders.

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

BACKGROUND

In women with obesity, excess gestational weight gain (≥270 g/week) occurs in two out of three pregnancies and contributes to metabolic impairments in both mother and baby. To improve obstetrical care, objectively assessed information on energy balance is urgently needed. The objective of this study was to characterize determinants of gestational weight gain in women with obesity.

METHODS

This was a prospective, observational study of pregnant women with obesity. The primary outcome was energy intake calculated by the energy intake-balance method. Energy expenditure was measured by doubly-labeled water and whole-room indirect calorimetry and body composition as 3-compartment model by air displacement plethysmography and isotope dilution in early (13-16 weeks) and late pregnancy (35-37 weeks).

RESULTS

In pregnant women with obesity (n=54), recommended weight gain (n=8, 15%) during the second and third trimesters was achieved when energy intake was 125±52 kcal/d less than energy expenditure. In contrast, women with excess weight gain (67%) consumed 186±29 kcal/d more than they expended (P<0.001). Energy balance affected maternal adiposity (recommended: -2.5±0.8 kg fat mass, excess: +2.2±0.5, inadequate: -4.5±0.5, P<0.001), but not fetal growth. Weight gain was not related to demographics, activity, metabolic biomarkers, or diet quality. We estimated that energy intake requirements for recommended weight gain during the second and third trimesters were not increased as compared to energy requirements early in pregnancy (34±53 kcal/d, P=0.83).

CONCLUSIONS

We here provide the first evidence-based recommendations for energy intake in pregnant women with obesity. Contrary to current recommendations, energy intake should not exceed energy expenditure.

FUNDING

This study was funded by the National Institutes of Health (R01DK099175; Redman, U54GM104940 and P30DK072476; Core support).

TRIAL REGISTRATION

clinicaltrials.gov: NCT01954342.

Energy Expenditure in Pregnant Women with Obesity Does Not Support Energy Intake Recommendations

OBJECTIVE

This study aimed to identify factors that may predispose women to excess gestational weight gain (GWG).

METHODS

Seventy-two healthy women with obesity (30 class I, 24 class II, 18 class III) expecting a singleton pregnancy were studied at 13 to 16 weeks gestation. Energy expenditure (EE) was measured during sleep (SleepEE, average EE from 0200-0500 hours) in a whole-room calorimeter, and total daily EE (TDEE) over 7 days using doubly labeled water. Glucose, insulin, thyroid hormones, and catecholamines were measured.

RESULTS

Body composition explained 70% variability in SleepEE, and SleepEE accounted for 67% to 73% of TDEE. Though there was no evidence of consistent low metabolism, there was considerable variability. Low SleepEE was associated with insulin resistance and low triiodothyronine concentrations (both P = 0.01). Physical activity level was 1.47 ± 0.02. For women with SleepEE within 100 kcal/d of their predicted EE, TDEE was significantly less than the estimate (2,530 ± 91 vs. 2,939 kcal/d; P < 0.001) provided from the most recent gestational energy requirement model.

CONCLUSIONS

Pregnant women with obesity are inactive, possibly predisposing them to excess GWG. Current energy requirement models overestimate activity and may promote excess GWG in women with obesity. Furthermore, the observed large interindividual variability in basal metabolism may be important to consider when assessing the risk for excess GWG.

Quality, Features, and Presence of Behavior Change Techniques in Mobile Apps Designed to Improve Physical Activity in Pregnant Women: Systematic Search and Content Analysis

Background

Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity.

Objective

The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women.

Methods

A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified.

Results

Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality.

Conclusions

Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women.

Amant M, Beyl RA, Ravussin E, Redman LM. Increased Energy Intake After Pregnancy Determines Postpartum Weight Retention in Women With Obesity

CONTEXT

This study was designed to understand causes and critical periods for postpartum weight retention by characterizing changes in body composition, energy intake, energy expenditure and physical activity in women with obesity during pregnancy and postpartum.

DESIGN

In this prospective, observational cohort study, body composition (plethysmography), energy expenditure (doubly labeled water, whole-body room calorimetry), physical activity (accelerometry), metabolic biomarkers, and eating behaviors were measured. Energy intake was calculated by the intake-balance method for pregnancy, and for 2 postpartum periods (0 to 6 months and 6 to 12 months).

RESULTS

During the 18-month observation period, weight loss occurred in 16 (43%) women (mean ± SEM, -4.9 ± 1.6 kg) and weight retention occurred in 21 (57%) women (+8.6 ± 1.4 kg). Comparing women with postpartum weight loss and weight retention, changes in body weight were not different during pregnancy (6.9 ± 1.0 vs 9.5 ± 0.9 kg, P = 0.06). After pregnancy, women with postpartum weight loss lost -3.6 ± 1.8 kg fat mass whereas women with weight retention gained 6.2 ± 1.7 kg fat mass (P < 0.001). Women with postpartum weight loss reduced energy intake during the postpartum period (compared with during pregnancy) by 300 kcal/d (1255 kJ/d), while women with weight retention increased energy intake by 250 kcal/d (1046 kJ/d, P < 0.005). There were no differences in the duration of breastfeeding, eating behavior, or metabolic biomarkers.

CONCLUSIONS

Postpartum weight gain was the result of increased energy intake after pregnancy rather than decreased energy expenditure. Dietary intake recommendations are needed for women with obesity during the postpartum period, and women should be educated on the risk of overeating after pregnancy.

Food Photography Is Not an Accurate Measure of Energy Intake in Obese, Pregnant Women

Background

To improve weight management in pregnant women, there is a need to deliver specific, data-based recommendations on energy intake.

Objective

This cross-sectional study evaluated the accuracy of an electronic reporting method to measure daily energy intake in pregnant women compared with total daily energy expenditure (TDEE).

Methods

Twenty-three obese [mean ± SEM body mass index (kg/m2): 36.9 ± 1.3] pregnant women (aged 28.3 ±1.1 y) used a smartphone application to capture images of their food selection and plate waste in free-living conditions for ≥6 d in early (13-16 wk) and late (35-37 wk) pregnancy. Energy intake was evaluated by the smartphone application SmartIntake and compared with simultaneous assessment of TDEE obtained by doubly labeled water. Accuracy was defined as reported energy intake compared with TDEE (percentage of TDEE). Ecological momentary assessment prompts were used to enhance data reporting. Two-one-sided t tests for the 2 methods were used to assess equivalency, which was considered significant when accuracy was >80%.

Results

Energy intake reported by the SmartIntake application was 63.4% ± 2.3% of TDEE measured by doubly labeled water (P = 1.00). Energy intake reported as snacks accounted for 17% ± 2% of reported energy intake. Participants who used their own phones compared with participants who used borrowed phones captured more images (P = 0.04) and had higher accuracy (73% ± 3% compared with 60% ± 3% of TDEE; P = 0.01). Reported energy intake as snacks was significantly associated with the accuracy of SmartIntake (P = 0.03). To improve data quality, excluding erroneous days of likely underreporting (<60% TDEE) improved the accuracy of SmartIntake, yet this was not equivalent to TDEE (-22% ± 1% of TDEE; P = 1.00).

Conclusions

Energy intake in obese, pregnant women obtained with the use of an electronic reporting method (SmartIntake) does not accurately estimate energy intake compared with doubly labeled water. However, accuracy improves by applying criteria to eliminate erroneous data. Further evaluation of electronic reporting in this population is needed to improve compliance, specifically for reporting frequent intake of small meals. This trial was registered at www.clinicaltrials.gov as NCT01954342.

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

BACKGROUND

Intensive lifestyle interventions in pregnancy have shown success in limiting gestational weight gain, but the effects on mood and quality of life in pregnancy and postpartum are less known. The purpose was to quantify changes in mental and physical quality of life and depressive symptoms across pregnancy and the postpartum period, to determine the association between gestational weight gain and change in mood and quality of life, and to assess the effect of a behavioral intervention targeting excess gestational weight gain on these outcomes.

METHODS

A three group parallel-arm randomized controlled pilot trial of 54 pregnant women who were overweight or obese was conducted to test whether the SmartMoms® intervention decreased the proportion of women with excess gestational weight gain. Individuals randomized to Usual Care (n = 17) did not receive any weight management services from interventionists. Individuals randomized to the SmartMoms® intervention (n = 37) were provided with behavioral weight management counseling by interventionists either in clinic (In-Person, n = 18) or remotely through a smartphone application (Phone, n = 19). In a subset of 43 women, mood and mental and physical quality of life were assessed with the Beck Depression Inventory-II and the Rand 12-Item short form, respectively, in early pregnancy, late pregnancy, 1-2 months postpartum, and 12 months postpartum.

RESULTS

The SmartMoms® intervention and Usual Care groups had higher depressive symptoms (p < 0.03 for SmartMoms® intervention, p < 0.01 for Usual Care) and decreased physical health (p < 0.01) from early to late pregnancy. Both groups returned to early pregnancy mood and physical quality of life postpartum. Mental health did not change from early to late pregnancy (p = 0.8), from early pregnancy to 1-2 months (p = 0.5), or from early pregnancy to 12 months postpartum (p = 0.9), respectively. There were no significant intervention effects. Higher gestational weight gain was associated with worsened mood and lower physical quality of life across pregnancy.

CONCLUSION

High depressive symptoms and poor quality of life may be interrelated with the incidence of excess gestational weight gain. The behavioral gestational weight gain intervention did not significantly impact these outcomes, but mood and quality of life should be considered within future interventions and clinical practice to effectively limit excess gestational weight gain.

TRIAL REGISTRATION

NCT01610752 , Expecting Success, Registered 31 May 2012.

Body Composition During Pregnancy Differs by Obesity Class

OBJECTIVE

The aim of this study is to characterize changes in body composition during pregnancy in women with obesity.

METHODS

Fifty-four healthy women with obesity (class 1, 30-34.9 kg/m² : n = 25; class 2, 35-39.9 kg/m² : n = 21; class 3, ≥ 40.0 kg/m² : n = 8) expecting a singleton pregnancy were studied. Body composition was measured in early pregnancy (13-16 weeks), midpregnancy (24-27 weeks), and late pregnancy (35-37 weeks) using air displacement plethysmography, stable isotopes, and skinfold thickness measurements. Fasting glucose, insulin, and leptin were measured.

RESULTS

The gain in fat-free mass was lower in the second trimester compared with the third (2.7 ± 0.2 to 5.3 ± 0.2 kg; P < 0.001), whereas fat mass accumulation declined over time (0.6 ± 0.3 to -0.7 ± 0.4 kg; P = 0.005). Women with class 1 and 2 obesity gained 1.1 ± 0.7 kg of fat mass during pregnancy, while women with class 3 obesity lost 4.1 ± 0.6 kg (both P < 0.001). The difference in fat accumulation between obesity classes was observed only in the second trimester (P = 0.02). Gestational weight gain was associated positively with changes in plasma concentrations of insulin, leptin, and insulin resistance (all P < 0.01).

CONCLUSIONS

Gestational weight gain in pregnancy differs by obesity class and trimester. Women with class 3 obesity gain less body weight and fat mass. Fat mass gain is most likely preventable in the second trimester.

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

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

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

BACKGROUND

Accelerated weight gain in infancy is a public health issue and is likely due to feeding behaviours.

OBJECTIVES

To test the accuracy of individuals to dispense infant formula as compared with recommended serving sizes and to estimate the effect of dispensing inaccuracy on infant growth.

METHODS

Fifty-three adults dispensed infant formula powder for three servings of 2, 4, 6, and 8 fl oz bottles, in random order. The weight of dispensed infant formula powder was compared with the recommended serving size weight on the nutrition label. A novel mathematical model was used to estimate the impact of formula dispensing on infant weight and adiposity.

RESULTS

Nineteen percent of bottles (20 of 636) prepared contained the recommended amount of infant formula powder. Three percent were underdispensed, and 78% of bottles were overdispensed, resulting in 11% additional infant formula powder. Mathematical modelling feeding 11% above energy requirements exclusively for 6 months for male and female infants suggested infants at the 50th percentile for weight at birth would reach the 75th percentile with increased adiposity by 6 months.

CONCLUSIONS

Inaccurate measurement of infant formula powder and overdispensing, which is highly prevalent, specifically, may contribute to rapid weight gain and increased adiposity in formula-fed infants.

Amant M, Beyl RA, Ravussin E, Redman LM. Propensity for adverse pregnancy outcomes in African-American women may be explained by low energy expenditure in early pregnancy

Background

African-American (AA) women have poorer pregnancy outcomes, and studies in nonpregnant women suggest a different etiology of weight gain in AA compared with white women. We hypothesized that physiologic factors such as low energy expenditure and physical activity would be present in AA compared with white women in pregnancy.

Objective

We aimed to identify physiologic risk factors for disordered energy balance in AA and white women early in pregnancy.

Design

This was a cross-sectional study in 66 pregnant women with obesity, between 14 and 16 wk of gestation. Energy intake was calculated using the intake-balance method. Energy expenditure was measured in free-living conditions [total daily energy expenditure (TDEE)] over 7 d with the use of doubly labelled water and during sleep [sleeping EE (SleepEE)] in a room calorimeter. Body composition was measured by air displacement plethysmography and physical activity by accelerometers. Markers of metabolic health were obtained from fasting blood and urine.

Results

AA (n = 34) and white (n = 32) women were comparable in age (mean ± SEM: 27.7 ± 0.6 y), enrollment body mass index [mean ± SEM (in kg/m2): 36.9 ± 0.7], and body fat (mean ± SEM: 45.0% ± 0.6%). AA women had more fat-free mass (P = 0.01) and tended to be more insulin-resistant (homeostasis model assessment of insulin resistance, P = 0.06). Energy intake was significantly lower in AA than in white women (2499 ± 76 compared with 2769 ± 58 kcal/d, P = 0.001), although absolute TDEE was comparable (AA: 2590 ± 77 kcal/d; white: 2711 ± 56 kcal/d; P = 0.21). After adjusting for body composition, TDEE was significantly lower in AA women (-231 ± 74 kcal/d, P = 0.003), as was SleepEE (-81 ± 37 kcal/d, P = 0.03). Physical activity, substrate oxidation, and metabolic biomarkers (triiodothyronine and thyroxine concentrations, catecholamine excretion) were not significantly different between groups.

Conclusions

Body mass-adjusted energy expenditure is significantly lower in AA than in white pregnant women. Energy intake recommendations for pregnancy do not consider this difference and may therefore overestimate energy requirements in AA women. This may lead to unintentional overeating and contribute to the disparity of excess gestational weight gain and postpartum weight retention that is more prevalent in AA women. This trial was registered at clinicaltrials.gov as NCT01954342.

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

BACKGROUND

In the United States (US), the incidence and severity of COVID-19 infections, hospitalizations, and deaths are higher in Black compared to White residents. Systemic inequities and differences in health behaviors may contribute to disparities in COVID-19 health outcomes. The aim of this study was to examine the impact of COVID-19 stay-at-home orders on changes in health behaviors and anxiety in Black and White adults residing in the US.

METHODS

Beginning April 2020, the Pennington Biomedical Research Center COVID-19 Health Behaviors Study collected information on changes to employment, income, diet, physical activity, anxiety, and sleep patterns through a global online survey.

RESULTS

Of 4542 survey respondents in the US, 7% identified as Black and 93% as White. Prior to the COVID-19 stay-at-home orders, a greater proportion of Blacks compared to Whites reported earning < US$50,000 per year (p < 0.0001). A greater proportion of Blacks reported being laid off, working fewer hours, and working from home following COVID-19 stay-at-home orders (p < 0.0001 for all). In the overall sample, eating behaviors improved, physical activity decreased, sleep time prolonged, and anxiety heightened following COVID-19 stay-at-home orders (p < 0.01 for all), which were universal between Black and White respondents (p ≥ 0.315 for all).

CONCLUSIONS

This study highlights the disproportionate changes to employment and income in Blacks, with no differential impact on health behaviors and anxiety compared to Whites due to COVID-19 stay-at-home orders. As the COVID-19 pandemic continues, disproportionate changes to employment and income status may widen among Blacks and Whites, which may influence health behaviors and anxiety.

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

BACKGROUND

Less than one-third of women gain an appropriate amount of weight during pregnancy, which can influence the long-term health of both the mother and the child. Economically disadvantaged women are the most vulnerable to maternal obesity, excessive weight gain during pregnancy, and poor birth outcomes. Effective and scalable health care strategies to promote healthy weight gain during pregnancy specifically tailored for these women are lacking.

OBJECTIVE

This paper presents the design and protocol of a biphasic, community-based eHealth trial, SmartMoms in WIC, to increase the adherence to healthy gestational weight gain (GWG) recommendations in low-income mothers receiving women, infant, and children (WIC) benefits.

METHODS

Phase 1 of the trial included using feedback from WIC mothers and staff and participants from 2 community peer advisory groups to adapt an existing eHealth gestational weight management intervention to meet the needs of women receiving WIC benefits. The health curriculum, the format of delivery, and incentive strategies were adapted to be culturally relevant and at an appropriate level of health literacy. Phase 2 included a pragmatic randomized controlled trial across the 9 health care regions in Louisiana with the goal of enrolling 432 women. The SmartMoms in WIC intervention is an intensive 24-week behavioral intervention, which includes nutrition education and exercise strategies, and provides the technology to assist with weight management, delivered through a professionally produced website application.

RESULTS

Phase 1 of this trial was completed in July 2019, and recruitment for phase 2 began immediately thereafter. All data are anticipated to be collected by Spring 2023.

CONCLUSIONS

The SmartMoms in WIC curriculum was methodically developed using feedback from community-based peer advisory groups to create a culturally relevant, mobile behavioral intervention for mothers receiving WIC benefits. The randomized clinical trial is underway to test the effectiveness of a sustainable eHealth program on the incidence rates of appropriate GWG. SmartMoms in WIC may be able to offer an innovative, cost-effective, and scalable solution for GWG management in women served by WIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04028843; https://clinicaltrials.gov/ct2/show/NCT04028843.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18211.

Development and Application of the Remote Food Photography Method to Measure Food Intake in Exclusively Milk Fed Infants: A Laboratory-Based Study

Background

Accurate methods of assessing food intake in infants are needed to assess the relationship between infant feeding practices and risk of childhood obesity. Current methods are either subjective or have limited ability for use beyond clinical research settings.

Objective

To assess the accuracy of the RFPM to evaluate simulated milk intake including energy, macronutrient, and micronutrient intake compared to direct weighing within a controlled study.

Methods

Individuals were recruited to prepare three 2 fl oz, 4 fl oz, 6 fl oz, and 8 fl oz servings of infant formula and to capture photographs at different stages of preparation (dry powdered formula, prepared formula, and liquid waste) using the SmartIntake^® application. Gram weights of the bottles were obtained by the RFPM and direct weighing. Using the United States Department of Agriculture National Nutrient Database for Standard Reference, energy, macronutrient, and micronutrient values were generated from gram weights.

Results

Intake of formula prepared from powder measured by the RFPM was equivalent to weighed intake within 7.5% equivalence bounds among all servings and each serving size. The mean difference between methods varied among servings sizes with the RFPM underestimating intake by 1.6 ± 0.4 kcals in 2 fl oz servings, 4.8 ± 0.6 kcals in 4 fl oz servings, and 6.2 ± 1.0 kcals in 6 fl oz servings, and overestimating intake by 0.1 ± 1.2 kcals in 8 fl oz servings. Bland-Altman analysis showed that the RFPM overestimated intake at lower levels food intake and underestimated intake at higher levels. Considering photographs of only the prepared formula bottle and the bottle with formula waste to simulate ready-to-feed formula and human breast milk, intake estimated by the RFPM was equivalent to the directly weighed intake within 7.5% for all servings.

Conclusions

The RFPM has higher accuracy than subjective methods and similar accuracy as compared to the objective methods in estimating simulated intake of milk and formula with lower burden to caregivers. The RFPM is a viable method for measuring intake in exclusively milk fed infants by caregivers in a controlled environment with potential for widespread use in research and clinical practice.

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

BACKGROUND

Maternal diet and eating behaviors have the potential to influence the metabolic milieu in pregnancies complicated by obesity, with implications for the developmental programming of offspring obesity. Emerging evidence suggests that mindfulness during eating may influence metabolic health in non-pregnant populations, but its effects in the context of pregnancy is less well understood. This study explored the individual and combined effects of mindful eating and diet quality on metabolic outcomes among pregnant women with obesity.

METHODS

In 46 pregnant women (body mas index >30 kg/m2) enrolled in the MomEE observational study, mindful eating (Mindful Eating Questionnaire, MEQ) and energy-adjusted dietary inflammatory index (DII, from 7 days of food photography) was assessed at two time points and the mean pregnancy values computed. Rate of gestational weight gain (GWG) and fat mass gain per week were determined from measured weight and body composition using a three-compartment method, respectively, at each assessment. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and ghrelin concentrations were determined from fasting blood samples in late gestation (35-37 weeks). Linear regression was used to examine the association of the MEQ and its subscales (where higher values indicate more mindful eating) with metabolic outcomes, adjusting for covariates: maternal age, pregravid body mass index, race, parity, DII. The effects of the MEQ*DII interaction was also tested.

RESULTS

Total MEQ scores were not associated with rate of weight or fat mass gain, although greater distracted eating behavior was associated with greater adiposity gain (weight and fat mass). Mindful eating was inversely associated with insulin resistance, although this was attenuated to non-significance after additional adjustment for GWG. Total MEQ and the external eating subscale was significantly inversely associated with fasted ghrelin, such that less tendency to eat under the influence of external cues was associated with lower ghrelin concentrations. After false discovery rate adjustment for multiple testing, only the association of the total MEQ and external eating subscale with ghrelin levels trended towards significance. The DII was not associated with MEQ scores or outcome variables, nor did it moderate the effect of MEQ on any of the outcomes.

CONCLUSION

This study generates early evidence to suggest that mindful eating holds potential as a tool to improve metabolic health outcomes in pregnant women with obesity, although further research is required on this topic. Prenatal lifestyle interventions should consider including mindfulness during eating to determine its efficacy for reducing adverse pregnancy and offspring health outcomes associated with maternal obesity.

Assessing Energy Requirements in Women With Polycystic Ovary Syndrome: A Comparison Against Doubly Labeled Water

CONTEXT

Weight loss is prescribed to offset the deleterious consequences of polycystic ovary syndrome (PCOS), but a successful intervention requires an accurate assessment of energy requirements.

OBJECTIVE

Describe energy requirements in women with PCOS and evaluate common prediction equations compared with doubly labeled water (DLW).

DESIGN

Cross-sectional study.

SETTING

Academic research center.

PARTICIPANTS

Twenty-eight weight-stable women with PCOS completed a 14-day DLW study along with measures of body composition and resting metabolic rate and assessment of physical activity by accelerometry.

MAIN OUTCOME

Total daily energy expenditure (TDEE) determined by DLW.

RESULTS

TDEE was 2661 ± 373 kcal/d. TDEE estimated from four commonly used equations was within 4% to 6% of the TDEE measured by DLW. Hyperinsulinemia (fasting insulin and homeostatic model assessment of insulin resistance) was associated with TDEE estimates from all prediction equations (both r = 0.45; P = 0.02) but was not a significant covariate in a model that predicts TDEE. Similarly, hyperandrogenemia (total testosterone, free androgen index, and dehydroepiandrosterone sulfate) was not associated with TDEE. In weight-stable women with PCOS, the following equation derived from DLW can be used to determine energy requirements: TDEE (kcal/d) = 438 - [1.6 * Fat Mass (kg)] + [35.1 * Fat-Free Mass (kg)] + [16.2 * Age (y)]; R2 = 0.41; P = 0.005.

CONCLUSIONS

Established equations using weight, height, and age performed well for predicting energy requirements in weight-stable women with PCOS, but more precise estimates require an accurate assessment of physical activity. Our equation derived from DLW data, which incorporates habitual physical activity, can also be used in women with PCOS; however, additional studies are needed for model validation.

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

OBJECTIVE

Maternal obesity increases the risks for adverse pregnancy and offspring outcomes but with large heterogeneity. This study examined changes to the maternal metabolic milieu across pregnancy in women with obesity. It identified differences between a metabolically unhealthy obesity (MUO) phenotype and a metabolically healthy obesity (MHO) phenotype, as well as the differences in offspring adiposity between the two metabolic phenotypes.

METHODS

In early pregnancy, women were classified with MHO (n = 13) or MUO (n = 9) based on the presence of zero or ≥2 risk factors for metabolic syndrome, respectively (systolic blood pressure > 130 mm Hg or diastolic blood pressure > 85 mm Hg, HDL cholesterol < 50 mg/dL, LDL cholesterol ≥ 100 mg/dL, triglycerides ≥ 150 mg/dL, and glucose ≥ 100 mg/dL). Area under the pregnancy concentration curve for glucose and triglycerides measured at early (13-16 weeks), mid- (24-27 weeks), and late (35-37 weeks) pregnancy, gestational weight gain (GWG), energy expenditure, maternal fat accretion, and infant body composition were compared.

RESULTS

Maternal BMI, GWG, and fat accretion did not differ between MUO and MHO. Women with MUO had a greater area under the pregnancy concentration curve for glucose (+2,170 [382] mg/dL·day, p < 0.001) and triglycerides (+12,211 [3,916] mg/dL·day, p < 0.001). There were no differences in late-pregnancy total daily energy expenditure, but activity energy expenditure was significantly lower in MUO (-403 [144] kcal). MUO offspring had greater weight (+621 [205] g, p = 0.01) and adiposity (+5.8% [2.1%], p = 0.02) at 1 week of life but showed no differences in fat-free mass.

CONCLUSIONS

Independent of GWG, MUO resulted in heightened exposure of fetal fat-promoting substrates. Differing metabolic phenotypes may explain heterogeneity of offspring adiposity born to women with obesity.

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

OBJECTIVE

The role of brown adipose tissue (BAT) in infant metabolism remains poorly understood, primarily because of the inherent limitation of positron emission tomography/computed tomography imaging to measure BAT, which is not suitable for infants. The aims of this method development study were to assess the feasibility, intra-rater reliability, interscan repeatability, and physiological relevance of measuring BAT in infants using magnetic resonance imaging (MRI).

METHODS

A total of 10 nonsedated infants (mean age, 22.6 [1.3] days old) completed two 3-T MRI exams using chemical-shift-encoded water-fat scans 6.2 (2.8) days apart. Candidate BAT voxels in the supraclavicular region were identified based on fat signal fraction (FSF). The volumes of BAT depots were manually traced, and FSF was calculated. Whole-body fat mass was determined using dual-energy x-ray absorptiometry.

RESULTS

Images were successfully obtained from 19 of 20 (95%) attempted scans. The mean BAT volume was 5.41 (SD 1.1) cm3 , and the mean FSF was 16.41% (SD 3.3%). Intra-rater analysis showed good reliability with no systemic bias (proportional bias for volume: p = 0.19; FSF: p = 0.30). Test-retest for interscan repeatability was good (intraclass correlation coefficients for volume: 0.92, p = 0.001 and intraclass correlation coefficients for FSF: 0.93, p < 0.001). FSF was inversely related to fat-free mass (r = -0.69, p = 0.03).

CONCLUSIONS

This method development study supports the use of MRI to obtain reliable and quantitative measurements of BAT volume in infants.

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

OBJECTIVE

To examine if eating behaviors in mothers with low income relate to attitudes toward infant feeding and whether associations differed between breastfeeding and formula-feeding mothers.

DESIGN

Cross-sectional study.

PARTICIPANTS

Forty postpartum women (aged ≥ 18 years, body mass index ≥ 25 and &lt; 40 kg/m²) in the Louisiana Women, Infants, and Children program participated in a telehealth postpartum intervention for health and weight loss.

MAIN OUTCOME MEASURE(S)

Maternal eating behaviors and infant feeding styles, assessed 6-8 weeks after birth (baseline) using validated questionnaires.

ANALYSIS

Significance was detected using independent t tests, chi-square tests for independence, or linear models (P &lt; 0.05).

RESULTS

Most mothers formula-fed (n = 27, 68%). In formula-feeding mothers, maternal disinhibition and perceived hunger were positively associated with restrictive infant feeding (β = 0.41, P &lt;0.001 and β = 0.41, P = 0.001, respectively). These relationships were significantly higher (Δ = -0.85, P = 0.006 and Δ = -0.59, P = 0.003, respectively) than among breastfeeding mothers. Comparatively, pressuring/overfeeding was lower in formula-feeding mothers than among breastfeeding mothers with dietary restraint (Δ slopes: 1.06, P = 0.02).

CONCLUSIONS AND IMPLICATIONS

In this cohort of mothers with low income, maternal eating behavior was associated with infant feeding styles only when feeding modality was considered. Mothers may benefit from education on how their eating behaviors can influence their infants and children.

Protocol for a randomised controlled trial of a weight maintenance intervention to promote fat loss in pregnant individuals with obesity

INTRODUCTION

In pregnancy, people with obesity or excess adiposity are prone to excess gestational weight gain (GWG) and have the highest risks for multiple maternal morbidities. Epidemiological studies suggest that the lowest incidence of adverse maternal and infant outcomes occurs with GWG lower than current recommendations (<5 kg) and with gestational weight maintenance, resulting in fat mass loss, in those with obesity. Data from randomised clinical trials are needed to evaluate the efficacy of a fat mass loss intervention on pregnancy outcomes. The objective of this proof-of-principle randomised controlled trial is to test the effect of a gestational fat mass loss intervention in pregnant individuals with obesity on changes in weight, fat mass and cardiometabolic disease risk factors.

METHODS AND ANALYSIS

In this two-site randomised parallel group, 100 women (30% black; 30% Hispanic) with pre-existing obesity (31.0≤body mass index≤55.0 kg/m2) are randomised to usual care (Provider Directed Group) or usual care plus a fat mass loss intervention with food provision (Weight Maintenance Group). The primary outcomes of the trial (Healthy Mamas/Mamis Saludables) are weight, fat mass (via three-compartment model) and cardiometabolic disease risk factors (ie, blood pressure, lipids, glucose, insulin) from baseline (~13 weeks gestation) to ~35 weeks gestation and at 2 weeks postpartum. Secondary aims evaluate the safety of the fat mass loss intervention during pregnancy and test the hypotheses that compared with usual care, the intervention will have no significant adverse effect on fetal growth, neonatal size, infant body composition and other adverse events. Mediators (eg, eating, activity) and moderators (eg, parity, obesity grade, race/ethnicity) of intervention effects are also examined. Finally, the study will explore the effect of prenatal fat mass loss on reducing the incidence of adverse obstetrical outcomes, including non-elective caesarean delivery, gestational diabetes, hypertension and pre-eclampsia.

ETHICS AND DISSEMINATION

The trial has been approved by the Pennington Biomedical Research Center Institutional Review Board, is monitored by an independent data and safety monitoring board and will be conducted in agreement with the Declaration of Helsinki. All results, positive, negative and inconclusive, will be disseminated at national and/or international scientific meetings and in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04731688.

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

INTRODUCTION

A key component to analyzing wearable sensor data is identifying periods of non-wear. Traditionally, strings of consecutive zero counts (e.g. >60-minutes) are identified indicating periods of non-movement. The non-movement window length is then evaluated as wear or non-wear. Given that non-movement is not equivalent to non-wear, additional criteria should be evaluated to objectively identify periods of non-wear. Identifying non-wear is especially challenging in infants due to their sporadic movement, sleep frequency, and proportion of caregiver-generated movement.

PURPOSE

To use hip- and ankle-worn ActiGraph wGT3X-BT (wGT3X-BT) data to identify non-wear in infants.

METHODS

Fifteen infant participants [mean±SD; age, 8.7±1.7 weeks (range 5.4-11.3 weeks); 5.1±0.8 kg; 56.2±2.1 cm; n = 8 females] wore a wGT3X-BT on the hip and ankle. Criterion data were collected during two, 2-hour directly observed periods in the laboratory. Using raw 30 Hz acceleration data, a vector magnitude and the inclination angle of each individual axis were calculated before being averaged into 1-minute windows. Three decision tree models were developed using data from 1) hip only, 2) ankle only, and 3) hip and ankle combined.

RESULTS

The hip model classified 86.6% of all minutes (wear and non-wear) correctly (F1 = 75.5%) compared to the ankle model which classified 90.6% of all minutes correctly (F1 = 83.0%). The combined site model performed similarly to the ankle model and correctly classified 90.0% of all minutes (F1 = 80.8%).

CONCLUSION

The similar performance between the ankle only model and the combined site model likely indicates that the features from the ankle device are more important for identifying non-wear in infants. Overall, this approach provides an advancement in the identification of device wear status using wearable sensor data in infants.

A Role for the Pregravid Maternal Milieu in the Intergenerational Transmission of Obesity

Objectives

Maternal obesity increases the risk for adverse pregnancy and offspring outcomes; however, with large heterogeneity. We hypothesize that in mothers with obesity, the heterogeneity of offspring adiposity is due to prolonged exposure to excess maternal substrates, namely glucose and triglycerides, which promote fetal fat accretion. The aims of this prospective observational study were to 1) examine the maternal metabolic milieu in pregnant women with metabolically unhealthy obesity, MUO and metabolically healthy obesity, MHO; and 2) identify if these maternal metabolic phenotypes in women with obesity influence infant adiposity.

Methods

During early pregnancy, 51 women with obesity were classified to have MUO (n = 9) or MHO (n = 13) based on the presence of zero (MHO) or ≥ 2 (MUO) risk factors for metabolic syndrome (SBP &gt; 130 or DBP &gt; 85, HDL &lt; 50 mg/dL, LDL ≥ 100 mg/dL, triglycerides ≥ 150 mg/dL, and glucose ≥ 100 mg/dL). Area under the pregnancy concentration curve (AUC) for glucose and triglycerides, gestational weight gain (GWG), fat accretion, and energy intake and expenditure from early (13–16 wks), mid (24–27 wks) to late (35–37 wks) pregnancy and infant fat mass were compared between groups.

Results

Compared to women with MHO, women with MUO were not different with respect to maternal BMI, GWG, fat accretion, energy and macronutrient intake, and energy expenditure. In both groups, maternal substrates changed similarly from ∼13 to ∼37 weeks of pregnancy, however MUO resulted in greater pregnancy AUC for glucose (+2169.7 ± 381.5 p &lt; 0.001 mg/dL · day) and triglycerides (+12,210.5 ± 3916.1 mg/dL · day, p &lt; 0.001). The offspring of women with MHO had significantly lower birth weight (−620.8 ± 204.6 g, p = 0.01), body fat percentage (−5.8 ± 2.1%, p = 0.02), and total fat mass (−268.8 ± 88.4 g, p = 0.01).

Conclusions

Differing obesity phenotypes in pregnancy may explain the heterogeneity of offspring adiposity. Metabolically unhealthy obesity resulted in a more prolonged exposure of fetal fat promoting substrates and increased adiposity at birth. This study identifies a population of women with obesity most in need of prenatal interventions and suggests that obesity phenotypes need to be considered when evaluating intervention effect on offspring outcomes.

Funding Sources

R01DK099175.