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Underserved pregnant women have a greater risk of excessive or inadequate gestational weight gain (GWG) and adverse perinatal outcomes. In the United States, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental nutrition and is uniquely positioned to deliver equitable interventions that support recommended GWG. Yet to date, no randomized controlled trials have evaluated behavioral strategies for managing GWG in this setting. The primary objective was to examine the effects of a statewide randomized multicomponent mobile eHealth lifestyle intervention trial on change in physical activity and sedentary time across pregnancy. The secondary objective was to explore associations between changes in physical activity, sedentary time, and GWG. A total of 351 pregnant women were recruited from the Louisiana WIC clinics and were randomly assigned to a multicomponent mobile eHealth intervention for GWG management (N=179) or usual care (N=172; standard in-person WIC care) prior to 16 weeks of gestation. The multicomponent mobile intervention included daily weighing, step tracking, counseling, exercise videos, health coach interactions, and social support. For the first objective, physical activity, including movement duration and movement context, and sedentary time were assessed at baseline (early pregnancy) and at the end of the intervention (late pregnancy) using accelerometry and the Pregnancy Physical Activity Questionnaire. For the second objective, GWG was determined based on weight collected at study visits in early and late pregnancy. Linear mixed models assessed intervention effects on physical activity and GWG. Both the Intervention Group and the Usual Care Group significantly increased sedentary time from early to late pregnancy (adjusted effect estimate [95% CI] 62 minutes per day (42-83), P<.001 and 52 minutes per day (31-72), P<.001, respectively). Both the Intervention Group and the Usual Care Group significantly decreased moderate activity (-13 minutes per day (-20 to -6), P<.001 and -10 minutes per day (-17 to -3), P=.01, respectively) and total moderate to vigorous physical activity (-14 minutes per day (-21 to -7), P<.001 and -10 minutes per day (-18 to -3), P=.01, respectively) from early to late pregnancy. For the Pregnancy Physical Activity Questionnaire, the Intervention Group reported an increase in sports participation across pregnancy compared with the Usual Care Group (+4 metabolic equivalent task (MET)-hours per week (2-7); P=.002). There were no associations between physical activity (-7 g (-32 to 18), P=.57) or sedentary time measures (4 g (-4 to 12), P=.31) and GWG. The first of its kind mobile eHealth multicomponent behavioral lifestyle intervention that included guidance to increase physical activity toward national guidelines did not meaningfully impact physical activity outcomes in pregnant women who were enrolled in Louisiana WIC. ClinicalTrials.gov NCT04028843; https://www.clinicaltrials.gov/study/NCT04028843. RR2-10.2196/18211.

Household chaos is an emerging risk factor for childhood obesity development, especially in families with lower socioeconomic status (SES). It is unclear if changes in household chaos, especially in pregnancy, may mediate the effectiveness of weight-related behavioral interventions. This study aimed to describe how household chaos changed across gestation and determine whether household chaos mediated the effect of an eHealth behavioral gestational weight gain (GWG) intervention in pregnant people with low SES. Pregnant people who were enrolled in the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were recruited for a randomized controlled trial testing the effectiveness of an eHealth-based pragmatic intervention for GWG management. The usual care group received the standard WIC program guidance and monthly health coach support with general pregnancy recommendations. The intervention group received the standard WIC program plus health information via email and weekly health coach discussions to promote healthy eating and adequate physical activity. Weight and household chaos were measured at baseline (early pregnancy, 10 to 16 weeks gestation) and at the end of the intervention (late pregnancy, 35 to 37 weeks gestation). Household chaos changes across time were examined using a paired t test for the continuous score and using the McNemar test for household chaos category (improved or no change vs declined). Serial linear regression models and mediation analyses assessed the relationship between the intervention group (predictor), household chaos change (mediator), and GWG (outcome) with adjustment for covariates. Among 258 participants, 53.9% (n=139) were Black, 43.4% (n=112) were nulliparous, 36.0% (n=93) were obese, and almost half (n=124, 48.1%) were classified as low household chaos at baseline. Overall, there were minimal changes in household chaos scores from early to late pregnancy (P=.34), although scores and categories tended to be higher in late pregnancy. Household chaos changes were divided; some improved or had no change (n=140, 54.3%), and some declined (n=118, 45.7%) across gestation. Household chaos did not mediate the effect of the intervention on GWG. In this sample, household chaos did not change across gestation and did not explain the effect of an eHealth behavioral GWG intervention in pregnant people with lower SES. Routine-focused and multilevel interventions may improve upon these findings to support an organized home for future parent and child health. ClinicalTrials.gov NCT04028843; https://www.clinicaltrials.gov/study/NCT04028843.

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

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.

IntroductionIn 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 analysisIn 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 disseminationThe 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.

Background An ability to switch between primarily oxidizing fat in the fasted state to carbohydrate in the fed state, termed metabolic flexibility, is associated with insulin sensitivity. Metabolic flexibility has been explored previously in women with polycystic ovary syndrome (PCOS), yet the independent or synergistic contributions of androgen excess and/or insulin resistance is not yet known. Therefore, the purpose of this article was to characterize metabolic flexibility in women with PCOS compared to women of normal BMI, obesity, or type 2 diabetes (T2DM). Methods Eighty-six weight-stable women; thirty with either PCOS ( n  = 30), or fifty-six with obesity ( n  = 12), T2DM ( n  = 27), or normal BMI ( n  = 17) underwent a hyperinsulinemic euglycemic clamp and indirect calorimetry to measure insulin sensitivity and substrate oxidation via indirect calorimetry, respectively. Results All analyses were adjusted for differences in age, ethnicity, and BMI between groups. Women with PCOS were less metabolically flexible compared to healthy women with obesity ( p  < 0.0001), normal BMI ( p  < 0.0001), but after controlling for glucose disposal rate, were similar to women with T2DM ( p  = 0.99). When dividing women with PCOS above and below the mean cutoff for insulin resistance, the insulin resistant women with PCOS had lower rates of non-oxidative glucose metabolism ( p  = 0.0001), higher levels of percent free testosterone ( p  = 0.04), a higher free androgen index ( p  = 0.006), more visceral adipose tissue ( p  = 0.02), and were less metabolically flexible ( p  = 0.007). Conclusions Women with T2DM were as metabolically inflexible as women with PCOS. When stratifying women with PCOS into those who are metabolically flexible and inflexible, the women who are inflexible display greater amounts of visceral fat and androgen excess. The inability to alter substrate use given the physiological stimulus may lead to subsequent increases in adiposity in women with PCOS thereby further worsening the insulin resistance. Trial registration number Clinical Trials.gov, NCT01482286 . Registered 30 November 2011.

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.

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. 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. 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. 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. 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.

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. 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). 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). 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. This study was funded by the National Institutes of Health (R01DK099175; Redman, U54GM104940 and P30DK072476; Core support). clinicaltrials.gov: NCT01954342.

Abstract 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.