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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 (13(0)-15(6) weeks) and late (35(0)-36(6)) 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±0:08h and varied by 1:37±0:07h across the six nights. TST and sleep efficiency significantly declined from early to late pregnancy (7:03±0:08h to 6:28±0:09h, p

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.

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

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.

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.

OBJECTIVES: During pregnancy, altered glucose kinetics coupled with disrupted sleep increase the risk for adverse metabolic health outcomes. The aim of this prospective, observational study in pregnant women with obesity was to 1) examine sleep patterns in early and late pregnancy; and 2) identify how changes in sleep patterns impact gestational weight gain, energy intake and metabolic health. METHODS: In 52 healthy pregnant women with obesity (27.4 ± 0.6 y; BMI: 36.3 ± 0.7 kg/m,(2)), energy intake (intake-balance method), and changes in weight, fasting glucose, insulin, lipids and habitual sleep (5 consecutive nights via wrist worn accelerometer) were assessed from early (13,(0)–15,(6) weeks) to late (35,(0)–36,(6)) pregnancy. A change to habitual sleep parameters (increase or decrease) was defined as ± one-half of the standard deviation of the 5-day measurement in early pregnancy. RESULTS: Results In early pregnancy, time spent in bed (TIB) was 9.40 ± 0.13 h and varied 1.61 ± 0.11 h across the 5 nights. Total sleep time (TST) and sleep efficiency (SE) significantly declined from early to late pregnancy 7.05 ± 0.13 h to 6.46 ± 0.15 h (P

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

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

The prevalence of excess gestational weight gain is increasing worldwide and is associated with pregnancy complications, including gestational diabetes mellitus, pre-eclampsia, preterm birth, macrosomia, and development of obesity in offspring. Whereas gestational weight gain positively correlates with the gain in fat mass (FM), fat-free mass (FFM) gain is relatively consistent across pregnancies. Commonly used methods to assess body composition include anthropometry, densitometry (air displacement plethysmography, underwater weighing), and hydrometry (isotope dilution, bioimpedance analysis). While these techniques can be applied to pregnancy, they require specific adjustments to assumptions inherent within each method, most importantly to accommodate for the hydration of FFM which is transient throughout gestation. Here we discuss the application of the abovementioned methods to pregnant women and the relevant adjustments needed to more accurately calculate FM based on body weight, body volume, or total body water. We also present a novel application of classical data to provide FFM density estimates for pregnant women at any stage of pregnancy. Use of these adjustments will help standardize assumptions on FFM hydration and minimize error in FM estimation. Techniques still fail, however, to fully distinguish tissue gains between mother and fetus. To fill this important gap, imaging techniques such as ultrasound and magnetic resonance imaging are being used more frequently and will provide more insight into fetal development, fetal adiposity, and depot specificity of maternal FM acquisition. Efforts to synchronize protocols are necessary to allow seamless comparison of data to advance the understanding of maternal body composition changes that contribute to pregnancy-related complications.

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 > 130 or DBP > 85, HDL

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.

Interventions to promote healthy pregnancy in women with obesity by improving diet quality have been widely unsuccessful. We hypothesized that diet quality is determined by eating behaviors, but evidence in women with obesity is lacking. We evaluated diet quality and eating behavior in 56 women with obesity (mean &plusmn, SEM, 36.7 &plusmn, 0.7 kg/m2, 46% White, 50% nulliparous) early in pregnancy (14.9 &plusmn, 0.1 weeks). Diet quality was objectively assessed with food photography over six days and defined by Healthy Eating Index. Eating behaviors were assessed by validated questionnaires. Women reported consuming diets high in fat (38 &plusmn, 1% of energy) and the HEI was considered &ldquo, poor&rdquo, on average (46.7 &plusmn, 1.3), and for 71% of women. Diet quality was independently associated with education level (p = 0.01), food cravings (p &lt, 0.01), and awareness towards eating (p = 0.01). Cravings for sweets and fast foods were positively correlated with respective intakes of these foods (p &lt, 0.01 and p = 0.04, respectively), whereas cravings for fruits and vegetables did not relate to diet intake. We provide evidence of the determinants of poor diet quality in pregnant women with obesity. Based on this observational study, strategies to improve diet quality and pregnancy outcomes are to satisfy cravings for healthy snacks and foods, and to promote awareness towards eating behaviors.

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

BackgroundHuman breastmilk contains pro- and anti-inflammatory compounds and hormones that can influence infant growth. However, little is known about the specific interrelationships between these compounds and whether their effects on infant growth may be influenced by pre-pregnancy weight status.ObjectiveThe purpose of this novel, prospective cohort study was to assess the interrelationships between pro-inflammatory cytokines (TNF-α, IL-6), hormones (insulin, leptin) and PUFAs (n-6, n-3) in blood and breastmilk in early postpartum between women with normal BMI (Group 1, n = 18; 18.5MethodsParticipants were robustly phenotyped along with their infants at 4-8 weeks postpartum. TNF-α, IL-6, insulin, leptin, and n-3 and n-6 PUFAs measured in blood and breastmilk and compared between pre-pregnancy BMI groups and with infant weight, length, head circumference and % fat mass.ResultsGroup 1 women had higher serum leptin (pConclusionsPro-inflammatory qualities of breastmilk were associated with infant growth measures regardless of maternal pre-pregnancy BMI. However, infants born to women with overweight or obesity demonstrated less responsive growth to breastmilk contents. More studies are needed to assess longitudinal effects of this impact.

Background Women with obesity are at increased risk for excess gestational weight gain. Studies in non-pregnant women suggest that the etiology of weight gain may be different between African-Ameri...

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.

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/m(2)): 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 (

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.

BackgroundTwo-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. ObjectiveThe aim of this study was to decrease the proportion of women who exceed the Institute of Medicine (IOM) 2009 GWG guidelines. MethodsIn 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. ResultsA 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