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Abstract Background Asians are at increased risk of morbidity at a lower body mass index (BMI) than European Whites, particularly relating to metabolic risk. UK maternal obesity guidelines use general population BMI criteria to define obesity, which do not represent the risk of morbidity among Asian populations. This study compares incidence of first trimester obesity using Asian-specific and general population BMI criteria. Method A retrospective epidemiological study of 502,474 births between 1995 and 2007, from 34 maternity units across England. Data analyses included a comparison of trends over time between ethnic groups using Asian-specific and general population BMI criteria. Logistic regression estimated odds ratios for first trimester obesity among ethnic groups following adjustment for population demographics. Results Black and South Asian women have a higher incidence of first trimester obesity compared with White women. This is most pronounced for Pakistani women following adjustment for population structure (OR 2.19, 95% C.I. 2.08, 2.31). There is a twofold increase in the proportion of South Asian women classified as obese when using the Asian-specific BMI criteria rather than general population BMI criteria. The incidence of obesity among Black women is increasing at the most rapid rate over time (p=0.01). Conclusion The twofold increase in maternal obesity among South Asians when using Asian-specific BMI criteria highlights inequalities among pregnant women. A large proportion of South Asian women are potentially being wrongly assigned to low risk care using current UK guidelines to classify obesity and determine care requirements. Further research is required to identify if there is any improvement in pregnancy outcomes if Asian-specific BMI criteria are utilised in the clinical management of maternal obesity to ensure the best quality of care is provided for women irrespective of ethnicity.

Aims: Type 2 diabetes is a chronic condition affecting increasing numbers of women of reproductive age. Recent UK data show more severe adverse offspring outcomes (stillbirth, neonatal death) than in infants of those with Type 1 diabetes. This systematic review aimed to evaluate randomised controlled trials (RCTs) undertaken in the pre-pregnancy, pregnancy and the postpartum periods in women with Type 2 diabetes, to optimise care and health outcomes., Methods: Six electronic databases were searched for eligible studies from January 2000 to September 2023; eligibility included RCTs of behavioural components, supplementation, pharmacotherapy and/or medical devices. Studies were screened in duplicate, and data were extracted on outcomes including behavioural, anthropometry, clinical measures and maternal and offspring outcomes. A narrative synthesis was performed., Results: Eleven trials (12 papers) were included (total 1356 women with Type 2 diabetes, n = 25-502). Ten interventions were conducted in pregnancy, and one in the postpartum period. No pre-pregnancy RCTs were identified. Interventions included pharmacotherapies and supplementation, a diabetes-specific antenatal programme, continuous glucose monitoring and postpartum exercise. We found a paucity of interventions limited by inadequate design, statistical power and poor reporting. The largest Type 2 diabetes pregnancy study to date demonstrated evidence of benefit for adding metformin to a standard insulin regimen compared to insulin alone. Other interventions need replication in larger studies among more diverse groups., Conclusion: This review identified few RCTs targeting women of reproductive age with Type 2 diabetes particularly lacking in the preconception and postpartum periods. Tailored pre-pregnancy, pregnancy and postpartum interventions for women with Type 2 diabetes to optimise care and health outcomes are urgently needed., (© 2024 The Author(s). Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Background: Maternal nutrition is crucial for health in pregnancy and across the generations. Experiencing food insecurity during pregnancy is a driver of inequalities in maternal diet with potential maternal and infant health consequences. This systematic review explored associations between food insecurity in pregnancy and maternal and infant health outcomes., Methods and Findings: Searches included 8 databases (MEDLINE, Embase, Scopus, Web of Science, PsychInfo, ASSIA, SSPC in ProQuest, and CINAHL), grey literature, forwards and backwards citation chaining, and contacting authors. Studies in high-income countries (HICs) reporting data on food insecurity in pregnancy and maternal or infant health, from January 1, 2008 to November 21, 2023 were included. Screening, data extraction, and quality assessment were carried out independently in duplicate. Random effects meta-analysis was performed when data were suitable for pooling, otherwise narrative synthesis was conducted. The protocol was registered on PROSPERO (CRD42022311669), reported with PRISMA checklist (S1 File). Searches identified 24,223 results and 25 studies (n = 93,871 women) were included: 23 from North America and 2 from Europe. Meta-analysis showed that food insecurity was associated with high stress level (OR 4.07, 95% CI [1.22, 13.55], I2 96.40%), mood disorder (OR 2.53, 95% CI [1.46, 4.39], I2 55.62%), gestational diabetes (OR 1.64, 95% CI [1.37, 1.95], I2 0.00%), but not cesarean delivery (OR 1.42, 95% CI [0.78, 2.60], I2 56.35%), birth weight (MD -58.26 g, 95% CI [-128.02, 11.50], I2 38.41%), small-for-gestational-age (OR 1.20, 95%, CI [0.88, 1.63], I2 44.66%), large-for-gestational-age (OR 0.88, 95% CI [0.70, 1.12] I2 11.93%), preterm delivery (OR 1.18, 95% CI [0.98, 1.42], I2 0.00%), or neonatal intensive care (OR 2.01, 95% CI [0.85, 4.78], I2 70.48%). Narrative synthesis showed food insecurity was significantly associated with dental problems, depression, anxiety, and maternal serum concentration of perfluoro-octane sulfonate. There were no significant associations with other organohalogen chemicals, assisted delivery, postpartum haemorrhage, hospital admissions, length of stay, congenital anomalies, or neonatal morbidity. Mixed associations were reported for preeclampsia, hypertension, and community/resilience measures., Conclusions: Maternal food insecurity is associated with some adverse pregnancy outcomes, particularly mental health and gestational diabetes. Most included studies were conducted in North America, primarily the United States of America, highlighting a research gap across other contexts. Further research in other HICs is needed to understand these associations within varied contexts, such as those without embedded interventions in place, to help inform policy and care requirements., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bell et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Food insecurity is a well-established obesity driver. Less is known about food insecurity during pregnancy. This review (PROSPERO:CRD42022311669) aimed to explore associations between food insecurity, maternal obesity, gestational weight gain (GWG), and nutrition. Searches included seven databases, gray literature, references, citations, and contacting authors. Observational studies reporting data from January 1st, 2008 to 21 November 2023 in high-income countries were included. Duplicate screening, data extraction, and quality assessments were performed. Random effects meta-analysis estimated odds ratios (OR), mean difference (MD), and 95% confidence intervals (CI). Narrative synthesis was conducted when data could not be pooled. Database searches identified 22,272 results; 20 studies were included (n = 19 North America, n = 1 Europe; n = 32,803 women). Food insecurity significantly increased obesity (OR 1.53 95%CI 1.39, 1.66), but not underweight (OR 1.12 95%CI 0.89, 1.34) or overweight (OR 1.18 95%CI 0.90, 1.46). Food insecurity significantly reduced GWG (MD -0.42 kg 95%CI -0.62, -0.22) and increased inadequate GWG (OR 1.16 95%CI 1.05, 1.28), but not excessive GWG (OR 1.04 95%CI 0.96, 1.13). Diet outcomes were inconsistent, with some evidence of reduced vitamin E and diet quality and increased red/processed meat consumption. Further studies outside of North America are needed to inform practice and policy to support maternal health., (© 2024 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Lower-intensity interventions delivered in primary and community care contacts could provide more equitable and scalable weight management support for postnatal women. This mixed-methods systematic review aimed to explore the effectiveness, implementation, and experiences of lower-intensity weight management support delivered by the non-specialist workforce. We included quantitative and qualitative studies of any design that evaluated a lower-intensity weight management intervention delivered by non-specialist workforce in women up to 5 years post-natal, and where intervention effectiveness (weight-related and/or behavioural outcomes), implementation and/or acceptability were reported. PRISMA guidelines were followed, and the review was prospectively registered on PROSPERO (CRD42022371828). Nine electronic databases were searched to identify literature published between database inception to January 2023. This was supplemented with grey literature searches and citation chaining for all included studies and related reviews (completed June 2023). Screening, data extraction and risk of bias assessments were performed in duplicate. Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Narrative methods were used to synthesise outcomes. Seven unique studies described in 11 reports were included from the Netherlands ( n  = 2), and the United Kingdom, Germany, Taiwan, Finland, and the United States ( n  = 1 each). All studies reported weight-related outcomes; four reported diet; four reported physical activity; four reported intervention implementation and process outcomes; and two reported intervention acceptability and experiences. The longest follow-up was 13-months postnatal. Interventions had mixed effects on weight-related outcomes: three studies reported greater weight reduction and/or lower postnatal weight retention in the intervention group, whereas four found no difference or mixed effects. Most studies reporting physical activity or diet outcomes showed no intervention effect, or mixed effects. Interventions were generally perceived as acceptable by women and care providers, although providers had concerns about translation into routine practice. The main limitations of the review were the limited volume of evidence available, and significant heterogeneity in interventions and outcome reporting which limited meaningful comparisons across studies. There is a need for more intervention studies, including process evaluations, with longer follow-up in the postnatal period to understand the role of primary and community care in supporting women's weight management. Public Health Wales was the primary funder of this review., Competing Interests: AJ is a Consultant in Public Health Medicine and AL is a Senior Public Health Practitioner from Public Health Wales. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Fong, Kenny, Thomson, Jesurasa, Lavans, Patterson, Sermin-Reed, Nguyen, Aquino, Cullen, O'Keefe, Moffat and Heslehurst.)

Background: Pregnancy weight management interventions can improve maternal diet, physical activity, gestational weight gain, and postnatal weight retention. UK guidelines were published in 2010 but health professionals report multiple complex barriers to practice. GLOWING used social cognitive theory to address evidence-based barriers to midwives' implementation of weight management guidelines into routine practice. This paper reports the pilot trial outcomes relating to feasibility and acceptability of intervention delivery and trial procedures., Methods: GLOWING was a multi-centre parallel-group pilot cluster RCT comparing the delivery of a behaviour change intervention for midwives (delivered as training workshops) with usual practice. The clusters were four NHS Trusts in Northeast England, randomised to intervention or control arms. Blinding of allocation was not possible due to the nature of the intervention. We aimed to deliver the intervention to all eligible midwives in the intervention arm, in groups of 6 midwives per workshop, and to pilot questionnaire data collection for a future definitive trial. Intervention arm midwives' acceptability of GLOWING content and delivery was assessed using a mixed methods questionnaire, and pregnant women's acceptability of trial procedures by interviews. Quantitative data were analysed descriptively and qualitative data thematically., Results: In intervention arm Trusts, 100% of eligible midwives (n = 67) were recruited to, and received, the intervention; however, not all workshops had the planned number of attendees (range 3-8). The consent rate amongst midwives randomised (n = 100) to complete questionnaires was 74% (n = 74) (95% CI 65%, 83%), and overall completion rate 89% (n = 66) (95% CI 82%, 96%). Follow-up response rate was 66% (n = 49) (95% CI 55%, 77%), with a marked difference between intervention (39%, n = 15) and control (94%, n = 34) groups potentially due to the volume of research activities. Overall, 64% (n = 47) (95% CI 53%, 75%) completed both baseline and follow-up questionnaires. Midwives viewed the intervention as acceptable and directly relevant to routine practice. The least popular components related to scripted role-plays. Pregnant women viewed the recruitment and trial processes to be acceptable., Conclusions: This rigorously conducted pilot study demonstrated feasibility intervention delivery and a high level of acceptability amongst participants. It has provided information required to refine the intervention and trial protocol, enhancing confidence that a definitive trial could be carried out., Trial Registration: ISRCTN46869894; retrospectively registered 25th May 2016, www.isrctn.com/ISRCTN46869894 ., (© 2024. The Author(s).)

Background: Women at risk of gestational diabetes mellitus (GDM) need preventative interventions., Objective: To evaluate targeted interventions before and during pregnancy for women identified as being at risk of developing GDM., Methods: Systematic review and meta-analysis conducted following PRISMA guidelines. MEDLINE, EMBASE and the Cochrane Library in addition to reference and citation lists were searched to identify eligible randomised controlled trials (RCTs) utilising risk stratification during the preconception period or in the first/early second trimester. Screening and data extraction were carried out by the authors independently. Quality assessment was conducted based on the Cochrane risk-of-bias tool. Random effects meta-analysis and narrative synthesis were performed., Results: Eighty-four RCTs were included: two during preconception and 82 in pregnancy, with a pooled sample of 22,568 women. Interventions were behavioural (n = 54), dietary supplementation (n = 19) and pharmacological (n = 11). Predictive factors for risk assessment varied; only one study utilised a validated prediction model. Gestational diabetes was reduced in diet and physical activity interventions (risk difference - 0.03, 95% CI 0.06, - 0.01; I 2 58.69%), inositol (risk difference - 0.19, 95% CI 0.33, - 0.06; I 2 92.19%), and vitamin D supplements (risk difference - 0.16, 95% CI 0.25, - 0.06; I 2 32.27%). Subgroup analysis showed that diet and physical activity interventions were beneficial in women with ≥ 2 GDM risk factors (risk difference - 0.16, 95% CI 0.25, - 0.07; I 2 11.23%) while inositol supplementation was effective in women with overweight or obesity (risk difference - 0.17, 95% CI 0.22, - 0.11; I 2 0.01%). Effectiveness of all other interventions were not statistically significant., Conclusions: This review provides evidence that interventions targeted at women at risk of GDM may be an effective strategy for prevention. Further studies using validated prediction tools or multiple risk factors to target high-risk women for intervention before and during pregnancy are warranted., (© 2024. The Author(s).)

Weight stigma is a well-recognised public health issue affecting many members of society including women during the preconception period. The impacts of preconception weight stigma on women are significant and may result in decreased access to and uptake of healthcare, and mental health concerns. The consequences of this weight stigma may translate to negative maternal outcomes and even intergenerational effects on the child. Eliminating weight stigma is therefore imperative. The aim of this paper is to report recommendations to reduce weight stigma for preconception women produced at a workshop with clinical and academic experts on preconception health and weight stigma at the 5th European Conference on Preconception Health and Care. The recommendations are related to two key areas: general societal recommendations prompting all people to acknowledge and adjust our attitudes towards larger-bodied people; and healthcare-specific recommendations imploring clinicians to upskill themselves to reduce weight stigma in practice. We therefore call for urgent approaches to address societal weight-stigmatising attitudes and norms related to both the general population and preconception women, while providing professional development opportunities for healthcare professionals relating to weight stigma. Eliminating weight stigma for preconception women may have positive impacts on the outcomes for mothers and children during pregnancy and beyond.

Preconception bariatric surgery improves obesity-related maternal pregnancy complications but may reduce the absorption of nutrients required for healthy fetal growth and development. Women who receive preconception nutritional support after bariatric surgery are less likely to have adverse pregnancy outcomes. This study aimed to investigate the provision of preconception and pregnancy-specific nutritional support for women having bariatric surgery in the UK. A mixed-methods survey was distributed to healthcare professionals working in obesity or maternity services between December 2018 and October 2019. We collected both quantitative and qualitative data which were analysed using a mixed-methods approach. We received 135 responses from online ( n = 99) and postal ( n = 36) questionnaires. Only 45% of participants reported being 'very familiar' with the preconception/pregnancy nutritional needs of this population. Barriers to providing nutritional support included: a lack of resources and time; poor communication both across services and with women; not having contact with women preconception; and a lack of information and guidance. Respondents felt that dietitians have the expertise in nutrition necessary to provide support; however, GPs and midwives have the most frequent patient access post-surgery, both before and during pregnancy. Optimal preconception and pregnancy-related nutritional support requires multidisciplinary care pre- and post-surgery, and healthcare professionals require training and guidance to inform practice.

Since the 2008 global financial crisis, there has been a rise in the number of people experiencing food insecurity. Particularly vulnerable are households with children. This systematic review and meta-ethnography of qualitative studies focuses on families' perceptions of food insecurity and how it affects children's nutritional health and wellbeing. Six electronic databases (Medline, Scopus, Web of Science, EMBASE, CINAHL and ASSIA), were searched for studies from European high-income countries between January 2008-July 2021, and supplemented by searches of grey literature databases, relevant websites, examination of reference lists and citation searches. We adhered to PRISMA and eMERGe guidelines to improve the completeness and clarity of meta-ethnographic reporting. Methodological quality of the studies were assessed using the Critical Appraisal Skills Programme qualitative checklist. We identified 11,596 records; we included 19 publications involving 813 participants in total. Data were synthesised according to Noblit & Hare's seven phases of meta-ethnography. We identified four key themes-food and eating practices, awareness, fragility, and networks of care-comprising five sub-themes. Our meta-ethnography provides a progressive 'storyline' of the children's experiences of food insecurity from both caregivers and children's perspectives. We found that children are aware of their family's limited resources and are often active in trying to help their families cope, and that food insecurity adversely impacts children's physical, psychological, and social experiences. Our analysis highlights gaps in knowledge about how food insecurity impacts children's nutritional health and wellbeing. It suggests that future research should prioritise minoritised ethnic communities, children living in temporary accommodation and caregivers of very young children., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Bell et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Black women in the UK face significantly higher risks of overweight and obesity and adverse pregnancy outcomes compared to women from other ethnic groups. Maternal nutrition plays a pivotal role in influencing the health outcomes of women and their children, especially during preconception and pregnancy. Cultural and environmental factors significantly influence the dietary experiences of African women after migration. This study explored the unique nutrition-related challenges faced by African migrant pregnant and postnatal women in the UK, and their nutrition support needs. Interviews were conducted with 23 African migrant women living in the UK, who were either pregnant or had a pregnancy within the past 3 years. These were analysed thematically, resulting in five overarching themes: food rituals and beliefs, pregnancy cravings, limited access to culturally appropriate food, limited access to culturally appropriate and evidence-based nutritional guidance, and the focus on healthy weight. The study identified challenges that African migrant women face in balancing their cultural heritage with the UK food environment and dietary recommendations, including potential implications on their health and pregnancy outcomes. It emphasised the importance of addressing these challenges through culturally sensitive approaches and tailored interventions, to enable informed decision making and enhance health outcomes for these women.

Introduction: Maternal obesity increases the risk of multiple maternal and infant pregnancy complications, such as gestational diabetes and pre-eclampsia. Current UK guidelines use body mass index (BMI) to identify which women require additional care due to increased risk of complications. However, BMI may not accurately predict which women will develop complications during pregnancy as it does not determine amount and distribution of adipose tissue. Some adiposity measures (eg, waist circumference, ultrasound measures of abdominal visceral fat) can better identify where body fat is stored, which may be useful in predicting those women who need additional care., Methods and Analysis: This prospective cohort study (SHAPES, Study of How Adiposity in Pregnancy has an Effect on outcomeS) aims to evaluate the prognostic performance of adiposity measures (either alone or in combination with other adiposity, sociodemographic or clinical measures) to estimate risk of adverse pregnancy outcomes. Pregnant women (n=1400) will be recruited at their first trimester ultrasound scan (11 +2 -14 +1 weeks') at Newcastle upon Tyne National Health Service Foundation Trust, UK. Early pregnancy adiposity measures and clinical and sociodemographic data will be collected. Routine data on maternal and infant pregnancy outcomes will be collected from routine hospital records. Regression methods will be used to compare the different adiposity measures with BMI in terms of their ability to predict pregnancy complications. If no individual measure performs better than BMI, multivariable models will be developed and evaluated to identify the most parsimonious model. The apparent performance of the developed model will be summarised using calibration, discrimination and internal validation analyses., Ethics and Dissemination: Ethical favourable opinion has been obtained from the North East: Newcastle & North Tyneside 1 Research Ethics Committee (REC reference: 22/NE/0035). All participants provide informed consent to take part in SHAPES. Planned dissemination includes peer-reviewed publications and additional dissemination appropriate to target audiences, including policy briefs for policymakers, media/social-media coverage for public and conferences for research TRIAL REGISTRATION NUMBER: ISRCTN82185177., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Maternal nutrition is essential for optimal health and well-being of women and their infants. This review aims to provide a critical overview of the evidence-base relating to maternal weight, obesity-related health inequalities and dietary interventions encompassing the reproductive cycle: preconception, pregnancy, postnatal and interpregnancy. We provide an overview of UK data showing that overweight and obesity affects half of UK pregnancies, with increased prevalence among more deprived and minoritised ethnic populations, and with significant health and cost implications. The existing intervention evidence-base primarily focuses on the pregnancy period, where extensive evidence demonstrates the power of interventions to improve maternal diet behaviours, and minimise gestational weight gain and postnatal weight retention. There is a lack of consistency in the intervention evidence-base relating to interventions improving pregnancy health outcomes, although there is evidence of the potential power of the Mediterranean and low glycaemic index diets in improving short- and long-term health of women and their infants. Postnatal interventions focus on weight loss, with some evidence of cost-effectiveness. There is an evidence gap for preconception and interpregnancy interventions. We conclude by identifying that interventions do not address cumulative maternal obesity inequalities and overly focus on individual behaviour change. There is a lack of a joined-up approach for interventions throughout the entire reproductive cycle, with a current focus on specific stages (i.e. pregnancy) in isolation. Moving forward, the potential power of nutritional interventions using a more holistic approach across the different reproductive stages is needed to maximise the benefits on health for women and children.

Preconception obesity is associated with adverse pregnancy outcomes and deprivation. The postnatal period provides an opportunity for preconception intervention. There is a lack of published postnatal behaviour and weight data to inform intervention needs. Secondary analysis of the GLOWING study explored postnatal diet, physical activity (PA) and weight among women living with obesity in deprivation. Thirty-nine women completed food frequency and PA questionnaires and provided weight measurement(s) between 3-12 months postnatal. Women's diet and PA fell short of national guidelines, especially for fruit/vegetables (median 1.6-2.0 portions/day) and oily fish (0-4 g/day). PA was predominantly light intensity. Patterns in weight change across time points indicated postnatal weight loss compared with 1st (median -0.8 to -2.3 kg) and 3rd-trimester weights (-9.0 to -11.6 kg). Weight loss was higher among women without excessive gestational weight gain (GWG) (-2.7 to -9.7 kg) than those with excessive GWG (2.3 to -1.8 kg), resulting in postnatal weight measurements lower than their 1st trimester. These pilot data suggest preconception interventions should commence in pregnancy with a focus on GWG, and postnatal women need early support to achieve guideline-recommendations for diet and PA. Further research in a larger population could inform preconception intervention strategies to tackle inequalities in maternal obesity and subsequent pregnancy outcomes.

Unlike various countries and organisations, including the World Health Organisation and the European Parliament, the United Kingdom does not formally recognise obesity as a disease. This report presents the discussion on the potential impact of defining obesity as a disease on the patient, the healthcare system, the economy, and the wider society. A group of speakers from a wide range of disciplines came together to debate the topic bringing their knowledge and expertise from backgrounds in medicine, psychology, economics, and politics as well as the experience of people living with obesity. The aim of their debate was not to decide whether obesity should be classified as a disease but rather to explore what the implications of doing so would be, what the gaps in the available data are, as well as to provide up-to-date information on the topic from experts in the field. There were four topics where speakers presented their viewpoints, each one including a question-and-answer section for debate. The first one focused on the impact that the recognition of obesity could have on people living with obesity regarding the change in their behaviour, either positive and empowering or more stigmatising. During the second one, the impact of defining obesity as a disease on the National Health Service and the wider economy was discussed. The primary outcome was the need for more robust data as the one available does not represent the actual cost of obesity. The third topic was related to the policy implications regarding treatment provision, focusing on the public's power to influence policy. Finally, the last issue discussed, included the implications of public health actions, highlighting the importance of the government's actions and private stakeholders. The speakers agreed that no matter where they stand on this debate, the goal is common: to provide a healthcare system that supports and protects the patients, strategies that protect the economy and broader society, and policies that reduce stigma and promote health equity. Many questions are left to be answered regarding how these goals can be achieved. However, this discussion has set a good foundation providing evidence that can be used by the public, clinicians, and policymakers to make that happen., Competing Interests: All authors declare no competing interests relevant to this conference report. ADM has received grants or contracts from Fractyl, Novo Nordisk and Randox, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novo Nordisk AstraZeneca, Currax and BI. HP has received grant funding paid to institutions, from Public Health England, the Office for Health Improvement and Disparities, and the National Institute for Health Research; honoraria for educational events from Johnson & Johnson; as well as honoraria for educational materials and accompanying presentations – arms length sponsorship and travel expenses for delivering an educational presentation from Novo Nordisk. She has also had unpaid leadership or fiduciary roles as a British Obesity and Metabolic Surgery Society council member, Obesity Empowerment Network professional steering group co-opted member and NICE weight management guidelines committee member. EFr has received research grants from NIHR (NIHR 152858; NIHR204247; NIHR300773; NIHR133099; NIHR203012; NIHR 13/164/51; RP-PG-0618-20008), and UKRI (BB/V004832/1); Royalties from authorship on an OUP Book from Oxford University Press; travel and accommodation support for attending the UK ASO22 conference from the Association for Study of Obesity, and travel support for attending an NIHR Academy training meeting in London as invited speaker from NIHR. She has also had leadership or fiduciary roles as an Elected Board member for the International Health Economics Association and a Member of NIHR Public Health Research funding panel. SB has received a grant paid to his employer, the Institute for Employment Studies IES, from Novo Nordisk to conduct research on obesity stigma in employment. IES retains full editorial control of all research outputs. AB has received researcher led research support and supported attendance of the Obesity Week/BOMSS 2022 from Novo Nordisk, and researcher led research grants from NIHR/BRC, Rosetrees Trust, MRC, BDA, BBSRC and Innovate UKRI. He has also received personal honoraria for presentations/chairing from Novo Nordisk, personal honoraria from Obesity UK and Johnson & Johnson, institutional fees from PHE and stocks from Reset Health Ltd. He has had unpaid leadership or fiduciary roles as Vice Chair Obesity Specialist Group for British Dietetic Association, Committee member OPEN, Scientific Council for British Nutrition Foundation, and Strategic Council for All Party Parliamentary Group on Obesity. JL has received grants or contracts, paid to institutions, from the National Institute of Health Research and personal consulting fees, support for attending meetings and/or travel, as well as participation on a Data Safety Monitoring Board or Advisory Board from Novo Nordisk. She is also a Current employee of AstraZeneca but was not at the time of this work and AstraZeneca had no role in this work. NI has received a grant from NIHR, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Obesity Empowerment Network, National Obesity Audit, Novo Nordisk and Johnson & Johnson, as well as support for attending meetings and/or travel from SQOT and BOMSS. She has also had leadership or fiduciary roles for Obesity Empowerment Network and BOMSS. ML has received consulting fees from Novo Nordisk and Nestle and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Nestle, Oviva, Roche and Novo Nordisk. SW has had travel costs paid by Novo Norisk for attendance at obesity conferences. KC has received payment for Lecture Apollo Endosurgery and speaking fees from Novo Nordisk. GKD has received research grants from Novo Nordisk and DDM, as well as payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novo Nordisk and J&J/Ethicon & Medtronic. SLB has received direct payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novo Nordisk and Guys & St Thomas Trust, as well as direct payment for expert testimony from Novo Nordisk. JM has an unpaid leadership or fiduciary role in the Association for the Study of Obesity as a Trustee. RLB has received personal payments for consulting fees from Novo Nordisk, Pfizer, Eli Lilly, ViiV, Gila and Therapeutics Ltd; personal payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from International Medical Press, Novo Nordisk, ViiV, Eli Lilly and Medscape; support for attending meetings and/or travel from Novo Nordisk and Eli Lilly, and personal payment for participation on a Data Safety Monitoring Board or Advisory Board from Novo Nordisk, Pfizer, Eli Lilly, ViiV, Gila and Therapeutics Ltd. She also has unpaid leadership or fiduciary roles as Chair of the Royal College of Physicians (RCPs) Advisory Group on Nutrition, Weight and Health, Member of the RCPs Advisory Group on Health Inequalities, Founding member, Trustee and Steering Group Chair for the Obesity Empowerment Network UK, Committee Member for BOMMS, Committee Member for NBSR, Co-opted Trustee ASO, and Co-Chair of NHS England Tier 3 and Tier 4 Clinical Advisory Group., (© 2023 The Authors.)

Introduction: Women and their infants are at increased risk of complications if gestational diabetes mellitus (GDM) or excessive gestational weight gain (GWG) occurs in pregnancy. Weight management interventions in pregnancy, consisting of diet and physical activity components are targeted based on maternal body mass index (BMI). However, the relative effectiveness of interventions targeted based on alternative measures of adiposity to BMI is unclear. This individual patient data (IPD) meta-analysis aims to explore whether interventions are more effective at preventing GDM and reducing GWG in women according to their level of adiposity., Methods: The International Weight Management in Pregnancy Collaborative Network has a living database of IPD from randomised trials of diet and/or physical activity interventions in pregnancy. This IPD meta-analysis will use IPD from trials identified from systematic literature searches up until March 2021, where maternal adiposity measures (eg, waist circumference) were collected prior to 20 weeks' gestation. A two-stage random effects IPD meta-analysis approach will be taken for each outcome (GDM and GWG) to understand the effect of early pregnancy adiposity measures on the effect of weight management interventions for GDM prevention and GWG reduction. Summary intervention effects with 95% CIs) will be derived along with treatment covariate interactions. Between-study heterogeneity will be summarised by I 2 and tau 2 statistics. Potential sources of bias will be evaluated, and the nature of any missing data will be explored and appropriate imputation methods adopted., Ethics and Dissemination: Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42021282036). Results will be submitted to peer-reviewed journals., Prospero Registration Number: CRD42021282036., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Maternal weight management is a priority due to pregnancy risks for women and babies. Interventions significantly improve maternal diet, physical activity, weight, and pregnancy outcomes. There are complex barriers to midwives' implementation of guidelines; low self-efficacy is a core implementation barrier. The GLOWING intervention uses social cognitive theory (SCT) to address evidence-based barriers to practice. The intervention aimed to support midwives' implementation of guidelines., Methods: An external rehearsal pilot cluster randomised controlled trial in four NHS Trusts (clusters) in England, UK. Clusters were randomised to intervention (where all eligible midwives received the intervention) or control (no intervention delivered) arms. A random sample of 100 midwives were invited to complete questionnaires pre- and post-intervention. UK guideline recommendations relating to midwives' practice were categorised into: 1) communication-related behaviours (including weight- and risk-communication), and 2) support/intervention-related behaviours (including diet/nutrition, physical activity, weight management, referrals/signposting). Questionnaires were developed using SCT constructs (self-efficacy, outcome expectancies, intentions, behaviours) and 7-point Likert scale, converted to a 0-100 scale. Higher scores were more positive. Descriptive statistics compared intervention and control arms, pre- and post-intervention., Results: Seventy-four midwives consented and 68 returned questionnaires. Pre-intervention, self-efficacy for support/intervention-related behaviours scored lowest. In controls, there was limited difference between the pre- and post-intervention scores. Post-intervention, mean (SD) scores were consistently higher among intervention midwives than controls, particularly for support/intervention self-efficacy (71.4 (17.1) vs. 58.4 (20.1)). Mean (SD) self-efficacy was higher post-intervention than pre-intervention for all outcomes among intervention midwives, and consistently higher than controls. Mean differences pre- and post-intervention were greatest for support/intervention self-efficacy (17.92, 95% CI 7.78-28.07) and intentions (12.68, 95% CI 2.76-22.59). Self-efficacy was particularly increased for diet/nutrition and physical activity (MD 24.77, 95% CI 14.09-35.44) and weight management (18.88, 95% CI 7.88-29.88) behaviours, which showed the largest increase in scores., Conclusions: This study supports the theoretical models used to develop GLOWING, where low self-efficacy was a core implementation barrier. Results suggest that GLOWING successfully targets self-efficacy, potentially with a positive impact on guideline implementation. A definitive trial is required to determine effectiveness., Trial Registration: ISRCTN46869894, retrospectively registered 25/05/2016, http://isrctn.com/ISRCTN46869894., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Heslehurst et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Two thirds of women report experiencing weight stigma during pregnancy. Newspaper media is powerful in framing health issues. This review synthesized UK newspaper media portrayal of maternal obesity. NexisUni was searched to identify newspaper articles, published January 2010 to May 2021, reporting content on obesity during pregnancy. Framework synthesis integrated quantitative and qualitative analysis of the content of articles. There were 442 articles included (59% tabloids and 41% broadsheets). Three overarching themes with interacting sub-themes were as follows: (1) Women were blamed for their weight, risks, and NHS impact. (2) Women were solely responsible for solving obesity, gendered from school age. (3) Women with obesity were a burden on individuals (e.g., themselves, their children, and health professionals), to society, and the NHS. Catastrophizing language framed the "problem," "scale," and "public health concern" of maternal obesity, emphasizing risk, and danger and was alarmist, aggressive, and violent as to elicit fear or devalue women. Articles platformed 'expert' voices rather than women's lived experiences. This review identified that UK newspaper media negatively frames and oversimplifies the topic of maternal obesity. Exposure to blaming and alarmist messaging could increase women's guilt, stigma, and internalized weight bias. The newspaper media should be harnessed to de-stigmatize maternal obesity and promote maternal well-being., (© 2022 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: Food insecurity is an increasingly important public health concern in high-income countries following the 2008 global financial crash, and recently with the COVID-19 pandemic. Food insecurity has been understood as a highly gendered issue, affecting more women than men. As women have more complex nutritional needs because of their menstrual cycle, pregnancy, and breastfeeding, the nutritional impact of food insecurity is also greater for women than for men. This systematic review aims to explore pregnant women's experiences of food insecurity in high-income countries and to understand how food insecurity affects their health, wellbeing, diet, and nutrition., Methods: We did a systematic review following PRISMA reporting guidelines. A comprehensive search strategy was developed using search terms such as "food insecurity" and "pregnancy outcomes". We searched seven databases (MEDLINE, Embase, Scopus, Web of Science, PsychInfo, ASSIA, and CINAHL), grey literature, reference lists, and citations, as well as contacted authors. No language restrictions were used, and only studies primarily containing data collected from Jan 1, 2008, onwards were included. Database searches were completed in April 2022; supplementary searches are ongoing. Inclusion criteria is based on PECOS. Screening, data extraction, and quality assessment were done by two authors independently. This systematic review is registered on PROSPERO, number CRD42022311669., Findings: 27 studies met the inclusion criteria, with all studies published between 2015 and 2022. 24 (89%) of 27 studies were done in the USA, two (7%) in Canada, and one (4%) in the UK. Outcomes reported include dietary intake or dietary quality during pregnancy (seven [26%] of 27), gestational weight gain (seven [26%]), mental health (five [19%]), pregnancy outcomes including pregnancy complications, preterm birth, or birthweight (five [19%]), and other health outcomes or combination of nutrition, health, and wellbeing (three [11%]). Evidence synthesis is ongoing and will be complete by August, 2022., Interpretation: This systematic review suggests that food insecurity experienced during pregnancy was associated with negative health and nutrition outcomes. The rigorous searches are strengths of this study. A limitation is the restricted focus on studies done from 2008 onward. More research to guide efficient interventions that address food insecurity among pregnant women is needed., Funding: None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Since the 2008 global financial crisis, there has been a rise in the number of people experiencing food insecurity. Particularly vulnerable are mothers with young children, pregnant women, and lone parents (the majority of whom are women). This systematic review and meta-ethnography of qualitative studies focused on women's experiences of food insecurity and how it affects their nutritional health and wellbeing. Six electronic databases (Medline, Scopus, Web of Science, EMBASE, CINAHL and ASSIA), were searched from January 1, 2008-July 10, 2021, and supplemented by searches of grey literature databases, relevant websites, examination of reference lists and citation searches. We adhered to PRISMA and eMERGe guidelines to improve the completeness and clarity of meta-ethnographic reporting. Methodological quality of the studies was assessed using the Critical Appraisal Skills Programme qualitative checklist. We identified 11,589 unique records; we included 23 publications reporting data from 22 unique studies involving 647 women. Data were synthesised according to Noblit & Hare's seven phases of meta-ethnography. We identified two key themes - accessing sufficient food and embodying food insecurity - comprising seven sub-themes. Our meta-ethnography provides a progressive 'storyline' of women's experiences of food insecurity. This includes the ways in which women attempt to access sufficient food, are unable to meet their nutritional needs, and the ways in which this is embedded into their everyday lives and embodied in unhealthful physical, social, and mental nutritional health and wellbeing impacts. Our review emphasises that food insecurity directly and tangibly impacts women's nutritional health and wellbeing. It concludes that there needs to be greater recognition of the psychosocial impact of food insecurity on vulnerable women in addition to its impact on their nutritional health and wellbeing., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Maternal obesity increases risks of adverse fetal and infant outcomes. Guidelines use body mass index to diagnose maternal obesity. Evidence suggests body fat distribution might better predict individual risk, but there is a lack of robust evidence during pregnancy. We explored associations between maternal adiposity and infant health. Searches included six databases, references, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. We included 34 studies (n = 40,143 pregnancies). Meta-analysis showed a significant association between maternal fat-free mass and birthweight (average effect [AE] 18.07 g, 95%CI 12.75, 23.38) but not fat mass (AE 8.76 g, 95%CI -4.84, 22.36). Women with macrosomic infants had higher waist circumference than controls (mean difference 4.93 cm, 95% confidence interval [CI] 1.05, 8.82). There was no significant association between subcutaneous fat and large for gestational age (odds ratio 1.06 95% CI 0.91, 1.25). Waist-to-hip ratio, neck circumference, skinfolds, and visceral fat were significantly associated with several infant outcomes including small for gestational age, preterm delivery, neonatal morbidity, and mortality, although meta-analysis was not possible for these variables. Our findings suggest that some measures of maternal adiposity may be useful for risk prediction of infant outcomes. Individual participant data meta-analysis could overcome some limitations in our ability to pool published data., (© 2022 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Maternal obesity increases pregnancy-related risks. Women with a body mass index (BMI) ≥ 30 kg/m 2 are considered to be at risk and should receive additional care, although approximately half will have uncomplicated pregnancies. This systematic review aimed to identify early pregnancy measures of adiposity associated with adverse maternal health outcomes. Searches included six databases, reference lists, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. Seventy studies were included with a pooled sample of 89,588 women. Meta-analysis showed significantly increased odds of gestational diabetes mellitus (GDM) with higher waist circumference (WC) categories (1.40, 95% confidence interval [CI] 1.04, 1.88) and per unit increase in WC (1.31, 95% CI 1.03, 1.67). Women with GDM had higher WC than controls (mean difference [MD] 6.18 cm, 95% CI 3.92, 8.44). WC was significantly associated with hypertensive disorders, delivery-related outcomes, metabolic syndrome, and composite pregnancy outcomes. Waist to hip ratio was significantly associated with GDM, hypertensive disorders, and delivery-related outcomes. Fat mass, neck circumference, skinfolds, and visceral fat were significantly associated with adverse outcomes, although limited data were available. Our findings identify the need to explore how useful adiposity measures are at predicting risk in pregnancy, compared with BMI, to direct care to women with the greatest need., (© 2022 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Obesity is a well-recognized risk factor for pregnancy complications. Most studies to date are in large cohorts, with results presented in a way that assumes all women living with obesity are at equal risk. This study investigates which women living with obesity are at higher risk of specific pregnancy complications. A systematic search of MEDLINE and Embase identified 7894 prospective or retrospective cohort studies exploring predictors of adverse outcomes among pregnant women living with obesity. Following screening, 61 studies were deemed eligible. Studies were selected if the effects of exposure to any predictor amongst pregnant women living with obesity could be collected. Maternal characteristics assessed for association with adverse outcomes included maternal age, race/ethnicity, maternal height, mode of conception, complement activation factors, and history of various comorbidities/procedures. Gestational diabetes mellitus was the most studied outcome ( n = 32), followed by preterm birth ( n = 29), preeclampsia ( n = 27), low birthweight infants ( n = 20), small for gestational age newborns ( n = 12), and stillbirth ( n = 7). This review identified important characteristics that should be considered during the screening and follow-up sessions of pregnant women living with obesity, including pre-existing type 1 diabetes, maternal age < 20 years or ≥35 years, non-White ethnicity, abdominal adiposity obesity, and history of bariatric surgery.

International guidelines recommend women with an overweight or obese body mass index (BMI) aim to reduce their body weight prior to conception to minimize the risk of adverse perinatal outcomes. Recent systematic reviews have demonstrated that interpregnancy weight gain increases women's risk of developing adverse pregnancy outcomes in their subsequent pregnancy. Interpregnancy weight change studies exclude nulliparous women. This systematic review and meta-analysis was conducted following MOOSE guidelines and summarizes the evidence of the impact of preconception and interpregnancy weight change on perinatal outcomes for women regardless of parity. Sixty one studies met the inclusion criteria for this review and reported 34 different outcomes. We identified a significantly increased risk of gestational diabetes (OR 1.88, 95% CI 1.66, 2.14, I 2  = 87.8%), hypertensive disorders (OR 1.46 95% CI 1.12, 1.91, I 2  = 94.9%), preeclampsia (OR 1.92 95% CI 1.55, 2.37, I 2  = 93.6%), and large-for-gestational-age (OR 1.36, 95% CI 1.25, 1.49, I 2  = 92.2%) with preconception and interpregnancy weight gain. Interpregnancy weight loss only was significantly associated with increased risk for small-for-gestational-age (OR 1.29 95% CI 1.11, 1.50, I 2  = 89.9%) and preterm birth (OR 1.06 95% CI 1.00, 1.13, I 2  = 22.4%). Our findings illustrate the need for effective preconception and interpregnancy weight management support to improve pregnancy outcomes in subsequent pregnancies., (© 2021 World Obesity Federation.)

Objectives: The aim of this study was to assess the relationship between deciles of area-level deprivation and seven adverse pregnancy outcomes in Wales., Design: Cross-sectional analysis., Setting: 64 699 live births in Wales from 31 March 2014 to 16 September 2019., Primary Outcome Variable: We examined each of the following seven adverse pregnancy outcomes: (1) small for gestational age (SGA); (2) large for gestational age; (3) preterm birth; (4) third-degree or fourth-degree perineal tear; (5) major postpartum haemorrhage (MPPH); (6) a lower Apgar score at 5 min and (7) emergency caesarean section., Results: There was no significant association between increasing aggregate measures of area-level deprivation and the adverse pregnancy outcomes we studied. Women living in an area with greater access to services are more likely to have a baby that is SGA (1.27, 95% CI 1.11 to 1.49), have a greater likelihood of a perineal tear (1.74, 95% CI 1.15 to 2.61), are significantly less likely to have MPPH (0.79, 95% CI 0.64 to 0.96), have a baby with an Apgar score of 0.26 higher (95% CI 0.22 to 0.29) and are significantly less likely to have an emergency caesarean section (0.81, 95% CI 0.73 to 0.88). Women living in areas with higher employment (0.26, 95% CI 0.19 to 0.36) and better health (0.26, 95% CI 0.19 to 0.35) were less likely to experience perineal tear., Conclusions: There was no clear social-spatial gradient in area-level deprivation and adverse pregnancy outcomes. We found a stronger association for individual-level behavioural risk factors than area-level factors. These findings support the benefits that accessible and holistic person-centred care may bring through addressing individual behavioural risk factors. There is a need for improved data completeness and further individual-level data on risk factors such as employment and income to better understand the role which may be played by population-level policies and their pathways to affecting outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Since the global financial crises of 2008, there has been a rise in the number of people experiencing food insecurity. The COVID-19 pandemic has exacerbated this. Many more are unable to afford or access food of sufficient quality and quantity to enable good health and well-being. Particularly vulnerable are mothers with young children, pregnant women and lone parents (the majority of whom are women). This review aims to understand experiences of food insecurity and how it affects women and children's nutritional health and well-being, focusing on experiences explicitly related to nutrition. Findings will help guide health policy and practice to support food-insecure women and children from high-income countries., Methods and Analysis: A systematic review and meta-ethnography exploring (1) food-insecure women's own accounts of their nutritional health and (2) food-insecure household's accounts of their children's nutritional health. Six major databases (MEDLINE, Scopus, Web of Science, EMBASE, CINAHL and ASSIA), grey literature databases and relevant stakeholder websites will be searched from 1 January 2008 to 30 March 2021. Reference list and citation searches will supplement electronic database searches. Outcomes of interest are accounts of nutrition and nutritional health, including diet, food practices, infant feeding practices and physical and mental health. The review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines, but as this is a meta-ethnography it will adhere to eMERGe Reporting Guidance for synthesis and writing findings of the final report. Critical Appraisal Skills Programme qualitative checklist will assess the quality of studies. A meta-ethnographic analysis will be conducted for all included studies., Ethics and Dissemination: As a qualitative systematic review, without primary data collection, ethical approval will not be required. Findings will be submitted for peer-reviewed publication., Prospero Registration Number: CRD42020214159., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Mothers with gestational diabetes mellitus (GDM) are at increased risk of pregnancy-related complications and developing type 2 diabetes after delivery. Diet and physical activity-based interventions may prevent GDM, but variations in populations, interventions and outcomes in primary trials have limited the translation of available evidence into practice. We plan to undertake an individual participant data (IPD) meta-analysis of randomised trials to assess the differential effects and cost-effectiveness of diet and physical activity-based interventions in preventing GDM and its complications., Methods: The International Weight Management in Pregnancy Collaborative Network database is a living repository of IPD from randomised trials on diet and physical activity in pregnancy identified through a systematic literature search. We shall update our existing search on MEDLINE, Embase, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database without language restriction to identify relevant trials until March 2021. Primary researchers will be invited to join the Network and share their IPD. Trials including women with GDM at baseline will be excluded. We shall perform a one and two stage random-effect meta-analysis for each intervention type (all interventions, diet-based, physical activity-based and mixed approach) to obtain summary intervention effects on GDM with 95% CIs and summary treatment-covariate interactions. Heterogeneity will be summarised using I 2 and tau 2 statistics with 95% prediction intervals. Publication and availability bias will be assessed by examining small study effects. Study quality of included trials will be assessed by the Cochrane Risk of Bias tool, and the Grading of Recommendations, Assessment, Development and Evaluations approach will be used to grade the evidence in the results. A model-based economic analysis will be carried out to assess the cost-effectiveness of interventions to prevent GDM and its complications compared with usual care., Ethics and Dissemination: Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42020212884). Results will be submitted for publication in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Maternal diet, physical activity (PA) behaviours, and gestational weight gain (GWG) are important for optimum health of women and their babies. This secondary analysis of the GLOWING pilot cluster trial explored these among women living with obesity in high deprivation. Pregnant women completed food frequency, PA and psychosocial questionnaires. Weights were retrieved from medical records and measured during routine appointments with midwives. Descriptive and regression analyses were stratified by obesity class. A total of 163 women were recruited; 54.0% had class 1 obesity, 25.8% class 2, 20.2% class 3, and 76.1% lived in the two most deprived quintiles. Women had suboptimal dietary intake, particularly for oily fish, fruit and vegetables. PA was predominantly light intensity, from household, care and occupational activities. Most women gained weight outside of Institute of Medicine (IOM) guideline recommendations (87.8%); women in class 3 obesity were most likely to have inadequate GWG below IOM recommendations (58.3%, p < 0.01) and reduced odds of excessive GWG compared with class 1 (AOR 0.13, 95% 0.04-0.45). Deprived women with obesity have a double inequality as both increase pregnancy risks. This population requires support to meet guideline recommendations for diet, PA and GWG. Further research exploring obesity classes would inform policies and care to achieve the best pregnancy outcomes.