MATERNAL ANTHROPOMETRIC MEASURES AND NUTRIENT INTAKE DURING THE SECOND AND THIRD TRIMESTERS OF PREGNANCY OF NORMAL

WEIGHT AND OVERWEIGHT GRAVIDAS

by

Diane Elaine Downing

Thesis submitted to the Faculty of the Virginia Polytechnic Institute and State University

in partial fulfillment of the requirements for the degree of

APPROVED:

S. J. Ritchey

F. C. Gwazdauskas

MASTER OF SCIENCE

in

Human Nutrition

L. Janette Taper, Chairman

C. S. Rogers

June, 1986

Blacksburg, Virginia

MATERNAL ANTHROPOMETRIC MEASURES ANO NUTRIENT INTAKE DURING

THE SECOND AND THIRD TRIMESTERS OF PREGNANCY OF NORMAL

WEIGHT AND OVERWEIGHT GRAVIDAS

by

Diane Elaine Downing

Committee Chairman: L. Janette Taper Human Nutrition and Foods

(ABSTRACT)

Weight, height, skinfold thicknesses, circumference measure-

ments and 72 hour food records were collected from pregnant

women (N=51) at four week intervals between the 12th and

40th weeks of gestation. Subjects were divided Into two

groups according to percent standard prepregnant weight for

height: overweight > 110% (N=17) and normal weight< 110%

(N=28). Changes In weight, skinfold thicknesses and circum-

ference measurements were slml lar between the two groups

during the third trimester (weeks 28 to 40 of gestation).

Significant increases In weight (1.58 kg per four weeks) and

waist circumference and significant decreases In calf and

abdominal skinfold thicknesses are reported. When the sec-

ond and third trimesters (weeks 12 to 40 of gestation) were

considered mean weight gain was 1 .87 kg per four week inter-

val. Overweight gravldas demonstrated a significantly

greater decrease in abdominal skinfold thickness than normal

weight gravldas. The patterns of change over the second and

third trimesters were different between the two groups for

abdominal, knee, and calf sklnfold thickness, hips and thigh

circumference, body fat and percent body fat. Caloric and

macronutrlent consumption were similar between

groups and did not change throughout the second

the two

and third

trimesters. Maternal weight gain was significantly asso-

ciated with infant birth weight in both groups.

ACKNOWLEDGEMENTS

I would I ike to express my sincere appreciation to the

fol lowing individuals for their advise, support and

friendship:

Dr. Taper for your dedication as an advisor, teacher

and dear friend.

Dr. Gwazdauskas, Dr. Ritchey, and Dr. Rogers for your

suggestions and support of this project, my internship in

Africa, and fellowship at The Kennedy Institute.

Mrs. Sharon Meyers for so graciously sharing your time

and expertise with me.

Mary and Fran for work Ing so we I I together to make

this a rewarding and enjoyable project.

Drew for your unselfish brotherly love.

Scott for your hugs,

explore my greatest dreams.

laughter, and trust to let me

Mom and Dad for your endless support and encouragement

of everyth Ing I pursue.

iv

TABLE OF CONTENTS

ACKNOWLEDGEMENTS • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page IV

LIST OF TABLES ...................................... VI I

LIST OF FIGURES. ..................................... V I

I •

I I •

I I I •

I V.

v. V I •

V I I •

INTRODUCTION . ................................ . REVIEW OF LITERATURE . ........................ . 3

A. I ntroductlon......................... 3 B. Components of maternal weight gain ••••••••• 4 C. Changes In maternal body composition ••••••• 10 D. Influence of maternal prepregnant weight and

pregnancy weight gain on Infant birth weight 15 E. Summary.................................... 32 MATERIALS AND METHODS ......................... A. B. c. D.

E. F. G.

Experimental design •••••••••••••••••• Recruitment of subjects •• • • • ••••••• Screening of subjects •••••••••••••• Proceedures for obtaining measurements: 1. Height ........................... 2. Weight •••••••••••••••• 3. Sklnfold thickness •••••••••••••• 4. Circumference ••••••••••••••••••••••• 5. Blood pressure •• • •••••••••• 6. Urfne analysis.... • ........•.•..•.. Body fat and Percent body fat determination 72 hour food record •••••••••• • •• Statistical analysis ••••••••••••••••••••

RESULTS

DISCUSSION

SUMMARY AND CONCLUSIONS

LITERATURE CITED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

V

34

34 35 36

37 37 38 39 40 40 41 41 42

44

64

70

72

VI I I. APPENDIXES Page

A. Suggested desireable weights for heights and ranges for adult females •••••••••••••••••••• 75

B. Medical History •••••••••••••••••••••••••••• 76 C. Socio-Demographic Information •••••••••••••• 78 D. Food and Health Habits ••••••••••••••••••••• 82 E. Exercise and Activity Level •••••••••••••••• 85 F. Food Knowledge and Bel lefs ••••••••••••••••• 89 G. Home Interview Information •••••••••••••••••• 90 H. 72 Hour Food Record ••••••••••••••••••••••••• 91 I. FI yer....................................... 92 J. Written Explanation •••••••••••• ; •••••••••••• 93 K. Consent Form • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 94 L. Example: 72 Hour Food Record •••••••••••••••• 96 M. Estimated Regression Equations with 95%

Confidence Intervals

1 • 2. 3. 4. 5. 6. 7. 8. 9.

1 0 • 1 1 • 1 2 • 1 3 • 1 4 • 1 5 • 1 6. 1 7 • 1 8. 1 9 •

Weight •••••••••••••••••••••••••••••••••• Trlcep sklnfoid thickness ••••••••••••••• Subscapuiar skinfold thickness •••••••••• Midaxillary sklnfold thickness •••••••••• Abdominal skinfold thickness •••••••••••• Supra I I lac sklnfold thickness ••••••••••• Thigh skinfold thickness •••••••••••••••• Knee sklnfold thickness ••••••••••••••••• Calf skinfold thickness ••••••••••••••••• Bust c I rcumference •••••••••••••••••••••• Waist circumference ••••••••••••••••••••• Hip circumference ••••••••••••••••••••••• Thigh circumference ••••••••••••••••••••• Calf circumference •••••••••••••••••••••• Ankle circumference ••••••••••••••••••••• Upper arm circumference ••••••••••••••••• Wrist circumference ••••••••••••••••••••• Body fat .•..•...•.••••.••.••..•...•...•• Percent body fat ••.••••••••••..•.••...••

99 100 1 0 1 102 103 104 105 106 107 108 109 11 0 1 1 1 11 2 t 1 3 11 4 1 1 5 11 6 1 1 7

IX. Vita •••••••••••••••••••••••••••••••••••••••••••••• 118

Vi

LIST OF TABLES

Page

1. Maternal weight gain by week of gestation ••••••••••• 6

2. The distribution of weight between maternal and feta I tissue........................................ 8

3. Description of overweight and normal weight subjects 45

4. The mean values for weight at each week of gestation for normal weight and overweight gravldas ••••••••••• 46

5. The mean skinfold measurements (mm) at each week of gestation for normal weight and overweight gravidas 47

6. The mean circumference measurements (cm) for normal weight and overweight gravldas ••••••••••••••••••••• 49

7. The mean body fat and percent body fat values for normal weight and overweight gravldas •••••••••••••• 51

8. Slope and Intercepts of I I nears equations flt to the observed mean values of each measurement during the third trimester for overweight and normal weight grav I das........................................... 53

9. Linear and quadratic coefficients and Intercepts of equations fit to the observed mean values of each measurement for overweight and normal weight sravidas during the second and third trimesters of pregnancy. 55

10. Caloric Intake of normal weight and overweight grav I das ••••••••••••••••••••••••.•••••••••••••••..•• 57

11. Protein Intake of normal weight and overweight grav I das •••••••••••••••••••••••••••••••••••••••••••• 5 8

12. Total Fat and Carbohydrate Consumption of normal and overweight gravldas ••••••••••••••••••••••••••••• 59

13. Macronutrlent analysis: mean nutrient Intake values of normal weight and overweight gravldas during the second and third trimesters •••••••••••••••••••••••••••••••• 60

14. Macronutrlent analysis: mean nutrient Intake of normal weight and overweight gravldas between the 12th and 40th weeks of gestation ••••••••••••••••••••••••••••• 61

15. Percentage of fat, carbohydrate and protein In the diet of normal weight and overweight gravldas ••••••• 63

16. Blrthwelght of Infants born to overweight and normal we I ght subjects..................................... 69

vii

LIST OF FIGURES

Page

1. Maternal Weight gain during pregnancy ••••••••••••• 5

2. The components of weight gain In normal pregnancy. 9

3. Absolute changes In sklnfold thickness during and after p reg nan cy................................... 11

4. Proportional changes In sklnfold thickness during and after p reg nan cy............................... 1 3

viii

INTRODUCTION

Optimal infant birth weight is the weight for gestation-

al age associated with minimum perinatal mortality. Birth

weight, because It is related to neonatal morbidity and

mortal tty, may be used to Indicate the success of pregnancy

and predict the future wel I being of the infant (Luke,

1979). Both low and excessive birth weight are associated

with increased neonatal mortality and perinatal comp I !ca-

tions Including: a higher Incidence of congenital abnormal I-

t I es, poor postnata I growth and Increased suscept i bi Ii ty to

infection (Beal, 1980) obstructed labor, shoulder dystocia,

postpartum hemorrhage, Infant! le injuries (Sach, 1955) and

Increased neonatal fatness (Edwards, 1978).

Maternal pregravld weight and pregnancy weight gain are

the strongest determinants of birth weight after gestational

age (Naeye, 1979; Jacobson, 1975). In general, low weight

women del Iver lower weight infants and overweight women

del Iver heavier Infants. However, women who enter pregnancy

with extremely high prepregnant weight and who restrict

weight gain during pregnancy are also at Increased risk to

del Iver low weight Infants (< 2.5 kg).

Maternal prepregnant weight and pregnancy weight gain

exert an Independent and additive effect on infant birth

weight (Simpson, 1975; Eastman and Jackson, 1968; Gormlcan,

1

2

1980). The combination of these two factors needed to pro-

duce an infant of optimal birth weight has yet to be defined

(Luke and Rosso, 1978).

The role of maternal fat stores, a component of both

maternal prepregnant weight and pregnancy weight gain, and

the mechanisms through which fat stores support pregnancy,

are not known. The purpose of this Investigation was to

characterize body fat deposition and mobi I izatlon In over-

weight and normal weight gravldas. Eventually, the mechan-

isms by which weight gain or loss affect the outcome of

pregnancy In overweight/obese women, wll I be elucidated.

With this Information overweight women of chi Id-bearing age

may be better counseled, before and throughout pregnancy, on

the nutritional requirements which may optimize the outcome

of pregnancy.

REVIEW OF LITERATURE

Luke and Petrie (1980) consider the anabolic state of

gestation to be composed of four Independent factors: normal

metabol lc maintenance, which includes correction of nutri-

tional deficits; metabol le costs of fetal growth and deve-

lopment; maternal nutritional reserves; and maternal weight

gain. Al I four factors must be present or available In

appropriate quantities to al low the successful outcome of

pregnancy. If any one or combination of factors Is abnormal

the pregnancy may result In either maternal or Infant com-

promise. The absence of maternal nutritional reserves, as In

the underweight gravlda, results In the unequal distribution

of maternal dietary Intake to alleviate the maternal deficit

and subsequent fetal Intrauterine growth retardation. When

maternal nutritional reserves are adequate, as in the nor-

mal weight gravlda, maternal weight gain is appropriately

divided between maternal maintenance and fetal growth and

results In a higher Infant birth weight. When obesity Is

superimposed on pregnancy an Increased metabolic requirement

occurs, In addition to the already Increased metabolic rate

of the pregnant woman. Once again a large percentage of the

maternal dietary Intake Is diverted to meet the needs of the

mother at the expense of the developing fetus.

3

4

.IllE COMPONENTS .Pf MATERNAL WEIGHT .Glil..N

There Is considerable Individual variation In maternal

weight gain which Is compatible with cl lnlcal normalcy

CNaeye, 1979; Hytten and Leitch, 1971). Therefore, perhaps

more Important than total weight gain In determining Infant

birth weight is the pattern and distribution of weight gain

during pregnancy (Pitkin, 1977, 1976, 1981). The first tri-

mester of pregnancy Is characterized by minimal weight gain

and is 11 lustrated by a sl lghtly sigmoid rate curve (Figure

1). The second and third trimesters are characterized by a

I I near rate of weight gain C 0.3 kg/week) Implying contin-

uous weight gain throughout the remainder of pregnancy. The

slope of the curve is greatest at mldgestatlon which corre-

sponds to the period of maximum rate of weight gain. (Pitkin

1976).

Hytten and Leitch (1971) suggest that the rate of

weight gain between 13 to 18; 18 to 28 and after 28 weeks of

gestation is 0.36 kg C0.8 lb.), 0.45 kg (1 lb.), and 0.36 to

0.41 kg (0.8-0.9 lbs) per week, respectively. An expected

weight gain by week of gestation ls described In Table 1.

Weight gain by week of gestation Is also described by Gueri,

et al. (1982) and ls based on a 20% weight Increase above

ideal prepregnant weight for height. The reference standard

of prepregnant weight for height was obtained from a regres-

sion analysis of weight for height of women 18 to 24 years

of age in the United States according to the Health and

5

Figure 1. Maternal weight gain during pregnancy.

30

28

24

...... 20

....., z 16 H < H 12 H

8

4

0 4 8 12 16 20 24 28 32 36 40

WEEKS OF GESTATION

Hytten and Leitch, 1971.

6

TABLE 1. Maternal weight gain by week of gestation.

Week of Gestation

1 0 20 30 40

Hytten and Leitch, (1971).

Weight Gain (kg) C lb)

650 4000 8500

12500

1 • 5 9.0

19.0 27.5

Nutrition

he l g t-1 t (cm)

Idea I I y,

achieved

Increase

7

Examination Survey (HANES) (1979) data: 0.53 x

- 25.55 = Ideal prepregnant weight for height.

a 1. 7% l ncrease In prepregnant weight (""-1 kg) Is

during the first trimester. The remaining 18.3%

in prepregnant weight (N10.8 kg) Is gained at a

rate of 0.678 kg/wk during the second and third trimesters.

The distribution of weight between maternal and fetal

tissue ls described in Table 2 and I I lustrated In Figure 2.

Most of the weight gained during the first and second tri-

mesters is attributed to expansion of maternal tissue. The

majority of the weight gained during the third trimester is

associated with development of fetal tissue (Pitkin, 1972).

The obi lgatory increase In weight associated with pregnancy

In a normal healthy woman ls estimated to be 12 kg of which

about 3.3 kg represents the weight of the fetus at term; 2.0

kg is attributed to Increases In uterine and placental

tissue, and amniotic fluid volume; kg ls accounted for by

Increased breast tissue; 1.5 kg is associated with fluid

retention; and 4 kg ls due to fat deposition.

The mean weight gain is often greater than the mean

accountable weight gain and the difference Is attributed to

maternal fat deposition (Luke, 1979). Four kilograms of fat

provides about 35,000 kcal (Prentice, 1981) which may be

uti I !zed during the last trimester of pregnancy when the

nutritional needs of the fetus are at their peak, or to

8

Table 2. The distribution of weight between maternal and fetal tissue.

Components of Weight Gain (Kg)

FETAL

Fetus Placenta Amniotic Fluid (Fetal Subtotal)

Maternal

Uterine size Breast size Blood volume Extracellular fluid (Maternal subtotal)

Total weight gain (Kg)

Pitkin et a I • C 197 2)

First

Trimester of Pregnancy

Second

Neg I I g I b I e Neg I I g I b I e Neg I I g I b I e

0.3 0. 1 0.3 o.o

(0.7)

0.7

1.0 0.3 0 •. 4

( 1. 7)

0.8 0.3 1.3 o.o

C 4. 1 )

4. 1

Third

3.4 0.6 1.0

C 5 • 0 )

1.0 0.5 1 • 5 1.5

(4.5)

9.5

9

Figure 2. The components of weight gain in normal pregnancy.

12 Maternal Stores

10 Tissue fluid ,...._ 8

tlO ;:.:: Blood '-' ..., 6 .c: Uterus tlO -~ Breast Q)

;:.: 4

Fetus Placenta

2 Liquor amnii

10 20 30 40

WEEKS OF GESTATION

Hytten and Leitch, 1971.

10

supplement lactation.

CHANGES ill rn COMPOSITIOH DURING PREGNANCY Seltchik et al. (1963) Investigated changes in body

composition during pregnancy to assess whether there was a

I imlt to water and fat-free tissue accumulation beyond which

fat or fluids accumulated. Body mass and body density values

were recorded throughout pregnancy and for 6 weeks postpar-

tum. A 2 kg net mass increase, associated with increased

body fat, was present in one third of the participants at

six weeks postpartum. However, no pattern of density change

during pregnancy was developed and there was no relation-

ship among Initial body mass, height, or density and subse-

quent change In density. The only significant correlation

was between body density and pregnancy weight gain or

de I I very weight I oss ( the weight I ost dur Ing de I I very and

the puerperlum). When total weight gain was less than 8.0

kg the density of the material gained was greater than 1 .00

gm/cm3. When weight gain exceeded 10 kg the density of the

material gained was less than 1.00 gm/cm3. A weight gain of

8.5 kg, equal to the obi igatory weight gain of pregnancy,

was associated with a gain of relatively high density mater-

ial: 1.050 to 1.068 gm/cm3. Greater weight gains were asso-

ciated with a decrease In body density consistent with

increased fat deposition. The authors concluded that among

a smal I group of wel I nourished healthy pregnant women a

11

Figure 3. Absolute changes in skinfold thickness .,..... during and after pregnancy • e e ""'6 Cl) Cl) i:,:, 5 sz u 4 H ::c: E-< 3 0 ,-..::i 0 2 Ii, z H ::.:: 1 Cl)

Ii, 0 0 i:,:,

~-1 ::c: U-2

10 20 30 38 1 6-8

WEEKS OF GESTATION

Taggart et al. 1967.

12

nutrient reserve threshold was reached above which fat and

water accumulated. Hi9h density material was not selec-

t Ive I y stored In excess of that accounted for by ob I I gatory

weight gain.

Skinfold

strate that

measurements taken during pregnancy

fat Is deposited prlmarl ly during the

demon-

second

trimester. Taggart et al. (1967) measured skinfold thick-

nesses CSFT) at seven sites during and after pregnancy:

biceps, triceps, subscapula, suprail iac, thigh, knee and

calf. Skinfold thickness Increased appreciably at al I

sites, except the knee, between 10 to 30 weeks of gestation

(Figure 3). The greatest absolute Increases occured at the

thigh and supra I I lac sites. The greatest proportional in-

crease occured at the supralllac site (Figure 4). Moderate

proportional Increases occurred at the subscapula, costal,

mid-thigh and biceps sites. Little or no change occurred at

the triceps or the knee.

Changes which occured between 30 to 38 weeks of gestation

were variable. Sklnfold thickness at the thigh continued to

increase, while SFT at the costal and triceps sites decreas-

ed. Skinfold thickness at the other sites showed I lttle

change. A significant decrease In total SFT (the sum of the

seven sklnfold measurements) occurred between the 38th week

of gestation and the first week postpartum. In general,

skinfold measurements Increased rapidly between 10 to 30

weeks of gestation and were greatest, both absolutely and

13

Figure 4. Proportional changes in skinfold thickness ,,... during and after pregnancy. ._, r/l lOD S..._PW.~11..IAC r/l (1) i:: u 130 'M ..c: .µ

"' 120 0

i:: 110 'M

rJl

i:: 100 'M (1) bO i:: 90 tll ..c: u

10 20 30 38 1 6-8

WEEKS OF GESTATION WEEKS POSTPARTUM

Taggart, et al., 1967

14

proportionately, at "central" sites and least at "perlpher-

al" sites. When SFT were compared between obese and non-

obese women, the obese women demonstrated sma I I er abso I ute

Increases. In addition, increments of total SFT were great-

est in those subjects with the smallest Initial skinfold

measurements. Total SFT Increased with increasing maternal

weight up to 30 weeks gestation; thereafter, total weight

continued to increase and total SFT decreased slightly.

Pipe et al. (1979) examined changes In body composition

during normal pregnancy and demonstrated slml lar patterns of

fat deposition as Taggart et at. (1967). Fat-free mass,

excess water and body fat increased during pregnancy; how-

ever, the patterns of Increase were different. Mean body

fat Increased 2.4 kg between 12 and 28 weeks of pregnancy,

reached a maximum between 24 to 28 weeks of gestation,

decreased sl lghtly during the remainder of pregnancy and

returned to initial values after delivery (6 to 15 weeks

postpartum). Skinfold thickness at the biceps, triceps,

subscapula and supra I I lac and fat eel I diameter, determined

through examination of subcutaneous adipose tissue, In-

creased rapidly between 12 and 26 weeks of gestation and

paralleled body fat increases. Mean total sklnfold thick-

ness attained a maximum value at 37 weeks gestation and fel I

to Initial va1ues between 6 to 15 weeks postpartum.

15

INFLUENCE .Qf PREPREGNANT WEIGHT AliD MATERNAL WEIGHT .G.A.U:! .Q.N INFANT BIRTH WEIGHT

Studies of two situations which resulted In an Increas-

ed Incidence of low birth infants stimulated concern about

the effect maternal nutritional status has on the outcome of

pregnancy. Antonov (1942) described the outcome of pregnan-

cy of women who suffered acute starvation due to longterm

food restriction during the siege of Lennlngrad. These women

were underweight before becoming pregnant and demonstrated

I imited weight gain throughout pregnancy. Infants born to

these mothers were, on the average, 500 to 600 grams I lghter

than expected and the Incidence of prematurity, st! I I births

and neonatal mortal tty was greater than expected. Smith

(1947) described the outcome of pregnancy of women In Hol-

land who experienced six months of food shortages during the

famine of 1944. These women were adequately nourished prior

to and entering pregnancy but failed to achieve adequate

weight gain during pregnancy. Mean Infant birth weight was

250 grams I lghter than expected but no Increases In the

Incidences of prematurity, st! I I births or congenital defects

were evidenced. These studies Indicated Increased fetal

mortal tty and a decreased trend In Infant birth weights as a

consequence of short term, acute maternal undernutrltlon.

Garn (1984) demonstrated that low birth weight babies,

born to low weight mothers, grow at slower rates than low

birth weight babies born to higher weight mothers who In

16

turn grow at slower rates than high birth weight babies born

to high weight mothers. Growth of the neonate was considered

reflect maternal body mass and a genetically programmed

course of development.

or low birth weight,

Therefore, neonates, whether of high

born to mothers of high prepregnant

weight, gain weight at a faster rate in both the short and

long term.

To determine the relationships among weight gain, pre-

pregnant wei9ht and Infant birth weight and the adequacy of

the 24 to 27 pound recommended weight Increase across sub-

groups of women, Naeye (1979) examined records of 44,565

maternal-Infant pairs who were fol lowed through The Col-

laborative Perinatal Project of the National Institute of

Neurological and Communicative Disorders and Stroke. The

women were divided Into four groups according to percent

prepregnant weight for height as defined by standards deve-

loped by The Metropolitan Life Insurance Company: under-

weight, < 90%; normal weight, 90 to 109%; moderately obese,

110 to 135%; and massively obese, > 135%. Each group was

further divided by percent optimal weight gain during preg-

nancy as derived by Hytten and Leitch (1979): average wei9ht

gain at 20 and 30 weeks gestation was 3.86 and 8.62 kg (8.5

and 19 pounds, respecctlvely), respectively. These values

and Intermediate values were used to establ lsh the optimal

cumulative weight galnand the percent optimal weight gain

for each week of pregnancy • Perinatal mortal lty rates were

17

assessed for each group and subgroup.

Assessment of perinatal mortal lty rates across percent

prepregnant weight and percent optimal weight gain groups

revealed that, among Infants born to women with desirable or

I ess than des I rab I e prepregnant weights, per I nata I morta I I ty

rates were lowest when pregnancy weight gains were between

80 to 120 percent of optimal values, or about 13.6 kg (30

lbs.). Perinatal mortality increased five fold when weight

gains were less than 25 percent of optimal values. In

contrast, infants born to the most overweight women had the

lowest mortal lty rate when maternal weight gain was between

24 to 52 percent of optimal values or 6.8 to 7.2 kgs (15 to

16 lbs.). Thus, optimal weight gain during pregnancy of an

overweight woman was about half that of an underweight

woman.

Excessive weight gain during pregnancy ( > 14.5 kg),

was associated with increased perinatal mortal lty rates

regardless of prepregnant weight. Although birth weights of

Infants born to overweight women were not as sensitive to

variation In maternal weight gain, perinatal mortality rates

were higher In more weight gain categories than In infants

born to nonoverweight women. Therefore, large maternal fat

stores did not ensure optimal outcomes of pregnancy when

weight gains were low or when mothers lost weight during

pregnancy.

18

Gormlcan et al. (1980) examined the effect of weight

gain and prepregnant weight on Infant birth weight In a

retrospective study of 787 white middle class women. Two

philosophies regarding optimal maternal weight gain were

compared. One advocated I imlted maternal weight gain during

pregnancy, particularly In overweight women, and was fol-

lowed by most physicians prior to 1970. The other recom-

mended I lberal lzed weight gain of 9.1 to 12.3 kg (20-27 lb)

and was adopted by most physicians after 1970. The data

from the women were initially classified Into two groups

based on their date of del Ivery: those who del lvered prior

to 1971 (restricted group) and those who del lvered after

1972 (unrestricted group). Percent standard weight for

height was computed from the weight taken at the first

obstetrical visit, usually between the 12 and 16th week of

gestation, using the Metropol ltan Life Insurance Company

Tables. Maternal prepregnant weight and weight gain at 12

and 16 weeks of gestation yield essentially Identical corre-

lations to Infant birth weight and longterm rate of Infant

weight gain (Garn, 1984). Total weight gain was calculated

as the weight Increase during the second and third trimes-

ters only. Within each.group patients were classified as

obese: > 120% standard weight for height; normal weight: 90

to 120% standard weight for height; or low weight: < 90%

standard weight for height.

19

Significant differences were found in percent standard

weight for height, weight gain and Infant birth weight bet-

ween the two date of del Ivery-determined comparison groups.

A 11.0 kg mean weight gain in the unrestricted group corre-

sponded to a mean infant birth weight of 3450 grams. A 7.2

kg mean weight gain In the restricted group corresponded to

a mean Infant birth weight of 3329 grams. The median ranges

of weight gain among nonrestrlcted and restricted women were

9.5 to 13.6 kg and 5.0 to 9.1 kg, respectively. When the

data of the two groups were combined and grouped according

to weight gain, mean Infant birth weights within each group

were slml lar, regardless of prepregnant weight. Thus, among

white middle-class women significant correlations exist

between both maternal weight gain during pregnancy and pre-

pregnancy weight and Infant birth weight. Maternal weight

gains of 20 to 30 pounds resulted in optimal Infant birth

weights.

Luke et al. (1984) suggest that adequate pregravld

weight and I lberal weight gain during pregnancy augment

optima I growth In Infants born to al I women, especially to

short women. The effect of maternal height, an indicator of

chronic nutritional status, and maternal weight at del Ivery,

an Indicator of gestational nutritional environment, were

studied to determine their Influence on Infant birth

weight. Del Ivery weight was defined as maternal pregravld

weight plus weight gain during pregnancy and was expressed

20

as the percent of the standard body weight for height as

determined by modified standards derived from the Metropol 1-

tian Life Insurance Company Table. Six hundred and nlnty-slx

maternal-Infant pairs were studied. The women were divided

Into three groups according to height: short(< 157.48 cm

(5'2"), average (157.5 to 167.6 (5'2" to 5'6") and tal I (>

167.6 cm ( 5'6"). Each group was then subdivided Into four

groups according to percent delivery weight: < 114.5 %,

underweight and/or weight gain less than or equal to 6.80;

114.5 to 124.4% normal weight and/or weight gain of 7.26 to

13.61 kg; 124.5 to 149.4%, moderately obese and/or high

weight gain of 14.06 to 22.68 kg; and> 149.4%, massively

obese and/or very high weight gain of> 22.68. Mean Infant

birth weight para I le led increasing percent del Ivery weight

In al I three stature groups and was most pronounced among

infants born to women of short stature. A 10% increase In

weight gain among short, average and tall women resulted in

a 127, 74 and 87 gram Increase In mean infant birth weight,

or a 23.32, 13.64; and 16.06 gm Increase In infant birth

weight per kg maternal weight gain, respectively. Mean

birth weight was slgnlficantly greater among Infants born to

tal I versus short gravldas across al I weight groups except

the most overweight. This suggests that: tal I women, inde-

pendent of prepregnant weight, del Iver Infants who weigh

more than Infants born to women of short stature and that

21

the effect of height on infant birth weight diminishes as

percent de I I very we I ght Increases.

Luke et al. (1984) also examined the influence of

height and percent del Ivery weight on intrauterine growth.

Growth retardation was defined as severe: < 10th percent! le,

(smal I for gestational age) and moderate: 10th to 25th

percentile. The incidence of both severe and moderate

growth retardation was inversly proportional to increasing

percent del Ivery weight among women of short and average

stature. Among tal I women the incidence of intrauterine

growth

with

retardation Initially decreased and then increased

increasing percent del Ivery weight. The Incidence of

excessive Intrauterine growth (moderate: 75th to 90th per-

cent 11 es and severe: > 90th percent 11 e) Increased with in-

creasing de 11 very we! ght percent among grav I das of a I I

height designations. A trend of Increased incidence of In-

trauterine growth retardation and decreased incidence of

excessive Intrauterine growth was noted among gravidas of

tal I stature and the highest del Ivery weight percent. This

trend supports earlier findings (luke, 198 that there Is a

threshold, after which maternal obesity and/or excessive

weight gain is disproportionately diverted to maternal main-

tenance at the expense of fetal growth. The absence of

severe growth retardation and the decl lne In incidence of

moderate growth retardation in Infants born to heavy women

of short stature support the theory that fetal growth may be

22

enhanced in women whose short stature Is the result of

Impaired nutritional status prior to conception.

Winikoff and Debrovner (1981) considered the effect of

maternal

paternal

prepregnant weight, height,

height and weight on infant

and weight gain

birth weight.

and

The

obstetric records of 259 white maternal-infant pairs were

examined to establish the effect of the five variables on

infant birth weight. The data were then divided Into three

groups according to percent prepregnant weight for height:

I lght, medium and heavy weight as determined using the

Metropo 11 tan LI fe Insurance Company standards. Materna I and

paternal heights and Infant birth weights were similar among

the three weight groups. When prepregnant weight was consi-

dered, weight gain during pregnancy and paternal height

were most highly correlated with infant birth weight among

low weight women. Prepregnant weight was the most highly

correlated variable with Infant birth weight among medium

weight women. Maternal height was the only variable slgnlfi-

cantly associated with

women.

infant birth weight among heavy

Therefore, among wel I nourished women, maternal height

did not Influence blrthwelght except among gravldas who were

considered overweight. The authors hypothesized that when

caloric reserves exceed the requirements to support preg-

nancy, as in the overweight woman, a more genetically pre-

23

disposed characteristic, such as maternal height, may play a

more important role in determining infant birth weight. In

contrast, the birth weight of infants born to low weight

women, who have fewer nutritional reserves, may be more

strongly influenced by environmental factors such as mater-

nal weight gain. Because women who compose the average

weight group have a wide range of nutritional stores, and

varing height, prepregnant weight may be the predominant

influence on infant birth weight.

Garn (1982) studied 44,000 mother-infant pairs through

The National Col laboratlve Perinatal Project of the National

Institute of Neurological Disorders and Stroke to determine

whether, and to what extent, "stature corrected" body mass

indices better predict Infant birth weight than maternal

pregregnant weight. Five different body mass indices were

computed from maternal height and prepregnant weight values:

welght/helght}l 2 helght/welght~ helght/weight; 12 weight/height2

and welght/helghff 2 The variabi I ity of infant birth weight

was least when calculations were based on maternal prepreg-

nant weight alone. Therefore, maternal prepregnant weight

was a better predictor of infant birth weight than any of

the height adjusted body mass Indices.

Luke and Petrie (1980) examined the relationship bet-

ween infant birth weight and maternal postpartum weight.

Two hundred and nlnty-four women were classified Into one of

three groups according to percent postpartum weight for

24

height (taken two days postpartum) by the Metropol ltaln Life

Insurance Tables (under weight: < 120%; normal weight: 120

to 159.9%; or overweight: > 160%).

The strongest correlation between mean birth weisht and

increasing percent postpartum weight was demonstrated by the

underweight group. A 214 gram increase In mean birth wei9ht

was associated with each 10% Increase in postpartum weight,

or 39.16 grams per kg Increase In maternal weight. Among

norma I weight grav i das, each 10% increase In postpartum

weight resulted In a 41.9 gram increase in mean birth

weight, or a 7.7 gram per kg Increase In maternal weight. A

negative relationship was demonstrated between birth weight

and Increasing postpartum weight among overweight gravidas.

A 10% Increase In postpartum weight resulted in a 29.8 gram

decrease In mean birth weight, or a loss of 5.5 grams per kg

Increase in maternal weight. The Incidence of growth retard-

ation was Inversely proportional to increasing postpartum

weight among underweight gravldas. There was no report of

severe growth retardation among the Infants born to over-

weight gravldas. However, the Incidence of moderate and

minimal growth retardation exceeded that of infants born to

normal weight women. The authors suggest that at both ex-

tremes of maternal pregravld weight, obese and underweight,

maternal dietary Intake is disproportionately al located to

correct maternal nutritional status while fetal growth is

25

compromised. Unless maternal weight gain is high a dispro-

portionate amount of the dietary Intake is diverted to meet

maternal needs In preference to fetal needs.

Edwards et al. (1978) compared the incidence of peri-

natal comp I !cations In 208 massively obese women and their

Infants with those of matched nonobese controls. Massive

obesity during pregnancy was associated with an increased

Incidences of Inadequate weight gain and excessive birth

weight; and a decreased Incidence of low birth weight.

Inadequate weight gain was associated with 20.6% and 5.3% of

the pregnancies among obese and nonobese mothers, respec-

tively. Infants born to obese and nonobese mothers who

gained less than 5.44 kg had mean birth weights of 3302 and

2875 grams (427 gram difference), respectively. In general,

the Infants of massively obese women weighed 209 grams more

at birth than Infants of nonobese mothers. Obese and non-

obese women who del lvered Infants weighing more than 4000

grams, gained an average of 8.66 kg (range: -14.1 to +24.95

kg) and 16.5 kg (range: +9.1 to +26.8 kg), respectively.

The authors suggested that massively obese women gain ap-

proximately 9.1 kg during pregnancy to provide the required

80,000 ki localorles to support pregnancy whl le preventing

excess fat deposition In the mother and in the fetus.

Harrison et al. (1980) Investigated prospectively the

associations between maternal obesity and fetal outcome.

Three hundred and twenty-seven women were classlfled into

26

one of three groups according to percent prepregnant weight

for height (NAS/NRC, 1980): massively obese: > 150%;

moderately obese: 120 to 150%; and nonobese: < 120%. Two

hundred and forty-nine women (69%) were not obese, 54

(16.4%) were moderately obese and 24 (7.5%) were massively

obese prior to pregnancy. Inadequate weight gain C < 5.44

kg) occurred more frequently among obese women (moderate, 19

% and massive, 15%) than nonobese women, 4%. When weight

gain exceeded 5.44 kg, maternal obesity was directly related

to Increased Infant birth weight. The mean birth weight of

Infants born to massively obese mothers was 516 grams heavi-

er than the mean birth weight of Infants born to mothers of

the other two weight groups. Although, the incidence of low

birth weight was the same among al I three groups, the Inci-

dence of excessive birth weight was significantly greater

among the massively obese women (33.3%) than either the

nonobese (8%) or moderately obese (9%).

George et al. (1984) Investigated prepregnant weight

and weight gain to determine which had the greater effect on

birth weight of Infants born to overweight women. Two popu-

lations of overweight women were studied retrospectively:

Hispanic migrant workers and white upper middle class pro-

fessionals. Subjects were divided Into five groups according

to percent prepregnant weight as determined by Jel I lffe

(1966): 100 to 110%, 110.1 to 125%, 125.1 to 140%, 140.1 to

27

150% and 150.1 to 199.9%. Infant birth weight para I le led

Increasing percent prepregnant weight among the more af-

and weight fluent participants only. Prepregnant weight

gain during pregnancy were not significantly correlated in

either group. Weight gain was related to Infant birth weight

In both groups. Prepregnant weight was slgnlflcantly corre-

lated with infant birth weight In the ~ormal weight and

overweight groups of affluent women only. Gravidas with

prepregnant weight in excess of 150% were at increased risk

for inadequate weight gain and for del Iver Ing smaller or LBW

infants. Forty-two percent of the low birth weight infants

were born to women in the most overweight group.

Luke and Rosso (1978) examined the correlation between

postpartum weight (maternal pregravld weight plus maternal

weight gain) and infant birth weight in 254 Black and

Hispanic maternal-Infant pairs. Postpartum weight, expres-

sed as percent standard weight for height as determined from

the Metropol !tan Life Insurance Company Tables, A I I near

correlation between postpartum weight and infant birth

weight was demonstrated up to 110% standard weight for

height. The rate at which birth weight increased with

respect

110% and

to Increased postpartum weight decreased between

125% and plateaued at 125% standard weight for

height. Adequate fetal growth was attained when the average

postpartum we)ght equal led or surpassed 110% standard weight

for height. Among obese women, 110% standard weight for

28

height was attained In spite of some weight loss. Under-

weight women had to gain weight equivalent to the pregravid

standard weight for height plus gain weight to support

pregnancy to achieve a postpartum weight of 110% standard

weight for height. A minimum weight gain of about 20 kg was

required by underweight women to al low optimal fetal growth.

The authors subsequently suggested that the current recom-

mendation for weight gain during pregnancy (10.9 to 12.2

kg) be reevaluated to more appropriately meet the needs of

pregnant underweight women.

Udal I et al. (1978) examined the effect of maternal

obesity and pregnancy weight gain (separately and combined)

on neonatal fatness. One hundred and nine mother-infant

pairs were examined within 72 hours of birth. Mothers were

divided into two groups: obese and nonobese by median pre-

pregnant weight for height as determined by National Academy

of Science (NAS) data (Committee on Dietary Allowances,

1980). Obesity was defined as> 120 percent median weight

for height. Infants were divided into three groups: large

for gestational age (LGA), appropriate for gestational age

(AGA), and smal I for gestational age (SGA). The LGA infants

were further divided Into fat and non-fat Infants according

to sum of eight skinfold thickness measurements and mid-arm

fat area. The mothers of LGA infants were significantly

heavier than the mothers of AGA infants before pregnancy:

29

76 +/- 19 kg and 58 +/- 11 kg, respectively. When the

mothers of the two groups of LGA infants were compared,

height and mean prepregnant weights were siml lar. However,

weight gain during pregnancy was significantly greater among

the mothers of the fat LGA Infants. Comparison of the two

LGA infant groups revealed that fatter LGA infants were also

longer and had significantly greater mid-arm fat areas than

the non-fat LGA Infants. Mid-arm muscle areas did not

differ between the two LGA infant groups.

Comparison of the obese and nonobese mothers revealed

that obese mothers delivered infants with significantly

greater skinfolds. Birthweight, length and head circumfer-

ence did not differ significantly. Multivariate analysis of

the association of maternal characteristics with neonatal

fatness indicated that maternal weight gain was associated

with increased fatness and length of the newborn. Prepreg-

nant weight was associated with increased fatness indepen-

dent of neonatal length.

Whitelaw (1976) examined the Influence of maternal

obesity on subcutaneous fat in the newborn; maternal-Infant

pairs CN=265) were examined within 48 hours of birth. Skin-

to Id th I cknesses were measured bi I atera I I y at four sites on

each neonate: biceps, triceps, subscapular and supra! I iac.

The sum of the measurements taken on the right side of the

body was calculated. Birth weight, length and head clrcum-

ference were measured. Maternal triceps skinfold was mea-

30

sured and compared to the standards for young women (Tanner,

1975). Women were classified as obese If their triceps

skinfold was greater than the 90th percentile, normal If

between the 10th to 90th percent! les and thin If lower than

the 10th percent I le. The Infants of obese women had sign!-

ficantly fatter skinfold measurements at every site than the

Infants of normal women. Similarly, the skinfold thickness-

es of Infants born to normal weight women were greater

the skinfold thicknesses of Infants born to thin women

than

at

every site except the subscapula. Maternal triceps sklnfold

thickness and weight gain were slgnlflcantly correlated with

the sum of the Infant's skinfolds. In addition, maternal

triceps skinfold thickness and weight gain were slgnlflcant-

ly correlated with birth weight.

Brown and Askue (1979) studied the effects of prepreg-

nant weight and weight gain on the growth of Infants In 600

maternal-Infant pairs.

height, maternal age,

They assessed prepregnant weight for

weight gain during each trimester,

Infant weight, length and head circumference measured at

birth, 3, 6, 9, and 12 months of age. They concluded that

weight gain during pregnancy Influenced Infant growth more

po~erful ly than maternal prepregnant weight; that Infants

born to underweight women were slgnlflcantly smaller than

Infants born to normal weight women Independent of weight

gain; that underweight women had slgnlflcantly shorter ges-

31

tatlonal periods than normal weight women; that the Inciden-

ce of infants with low birth weight was 2.5 times higher

among underweight women and 6 times higher among women

fall Ing to gain at least 9.1 kg compared to normal weight

women who gained at least 9.1 kg during pregnancy, and that

Infants born to normal weight women who gained less than 9.1

kg were sma I I er at birth, but demonstrated Increased catch-

up growth by one year of age compared to underweight women

who gained at least 9.1 kg during pregnancy. These results

suggest that weight gain exerts a strong effect on Infant

birth weight and that recommendations for weight gain should

be based on prepregnant weight.

Orestead et al. (1985) looked at the effect of maternal

nutritional counsel Ing and subsequent dietary Intake on

weight gain and Infant birth weight. The mothers from 200

maternal-Infant pairs were divided Into two groups by the

type of nutrition education they received during pregnancy.

One group received nutritional counsel Ing consisting of a

single group lesson. The other group, In addition to the

group lesson, participated in multiple Individual nutrition

counsel Ing sessions which emphasized appropriate weight gain

and dietary Intake. Sixty-four percent of the women who

received the group lesson gained Oto 7 kg. during the last

trimester. Seventy-two percent of the women who received

Individualized counsel Ing gained 7.1 to 14.0 kg during the

second and third trimesters. The counseled group started

32

cl lnlc visits earl ler, attended more cl lnics, gained more

weight and del lvered Infants with mean birth weights 100

grams greater than the uncounseled group. Four percent and

13 percent of the Infants of counseled and uncounseled women

respectively, weighed less than 2,500 grams. Maternal weight

gain and birth weight were significantly correlated. The

authors concluded that intensive nutritional counseling

effective In increasing maternal dietary Intake and

nancy weight gain and reducing the Incidence of low

weight Infants.

was

preg-

blrth

SUMMARY

Maternal prepregnant weight and pregnancy weight ~aln

exert an Independent and additive effect on Infant birth

weight. Next to gestational age they are the two strongest

Influences on birth weight. The recommended weight gain for

a normal weight woman during pregnancy is 22 to 27 pounds

and Is associated with minimum perinatal morbidity and mor-

tality rates. The optimal weight gain for obese women has

yet to be determined. It Is thought that overweight gravl-

das, because of their excess fat stores, require fewer

exogenous calories to support pregnancy. However, restrict-

ed weight gain among obese women during pregnancy has been

associated with an Increased Incidence of low birth weight

infants. It Is now evident that maternal prepregnant weight

status should be taken into consideration when weight gain

33

recommendations are made.

Recommendations of maternal weight gain for obese gra-

vidas vary in both absolute value and in reference standard.

Gormican (1980) suggests a 20 to 30 pound weight Increase

regardless of prepregnant weight. Naeye (1978) suggests

that obese women need only gain 15 to 16 pounds during

pregnancy to allow for optimal fetal growth. Guerl (1984)

showed that an Increase In weight to 20 percent above stand-

ard prepregnant weight for height was adequate to support

pregnancy.

Whether from the diet or from maternal fat stores, 80,000

additional calories are needed to support pregnancy. If

maternal dietary Intake is Insufficient, or If maternal fat

stores are inadequate or unuseable, metabol le catabol Ism is

Indicated resulting In both maternal and fetal compromise.

Women tend to accumulate fat stores at central sites

during the second trimester of pregnancy as demonstrated by

serial sklnfold measurements taken during pregnancy. Unfor-

tunately Information describing fat mob! I lzation during

pregnancy Is not as wel I documented. To elucidate the role

of maternal fat stores during pregnancy among women of

different prepregnant weight status wl 11 al low more appro-

priate recommendations of maternal weight gain and ultimate-

ly enhance the outcome of pregnancy.

MATERIALS AND METHODS

ExperJmental DesJgo

Healthy, pregnant Caucasian women, 20 to 38 years of

age were recruited between the 12th and 20th weeks of preg-

nancy to participate In an anthropometric study. Skinfold

thickness, body circumference, height, weight, blood pres-

sure, urine analysis and dietary Information were collected

every four weeks (+/- two weeks) between the 26th week of

gestation and del Ivery. Prepregnancy weight was recorded

as reported by each subject during the Initial Interview.

Each subject was classified, In retrospect, Into one of two

weight groups: normal weight or overweight as determined by

their prepregnant percent deslrable body weight for height

(Appendix A) (Committee on Dietary Allowances, 1980).

Height was measured at the Initial visit and assumed to

remain constant. Weight, skinfold thickness at eight sites:

tr I ceps, upper arm, subscapu I a, m I dax 11 I ary, supra 11 I ac,

abdomen, mldthlgh, knee and calf; and circumference measure-

ments at eight sites: upper arm, wrist, bust, waist, hips,

thigh, calf and ankle were taken at each visit. Blood

pressure and urine analysis were performed at each visit as

a precaut I onary measure on I y; the data co I I ected were not

analyzed for this study. Descriptive Information was ob-

tained on each participant during the lnltlal visit through

the completion of seven questionnaires: medical history

34

35

(Appendix B}, sociodemographic (Appendix C}, food and health

habits (Appendix D}, exercise and activity level (Appendix

E}, food knowledge and bel lefs (Appendix F} and an interview

Information sheet (Appendix G}. Each woman completed a 72

hour food record (Appendix H} prior to each appointment. Al I

measurements were made at the Sol ltude Bui I ding on the

Virginia Polytechnic Institute and State University campus.

Changes In I lfe style, food selection or food consumption

habits were not required In order to participate in the

study. Nutritional counsel Ing was not provided unless

requested. Any Information provided to a participant was

done to enhance her knowledge and understanding of the

nutritional needs during pregnancy.

Recruitment .o.f. SubJects Subjects were recruited through pub I lcly displayed

flyers (Appendix I} and advertisements which described the

study. Flyers were placed on bul letln boards located

throughout the Virginia Polytechnic Institute and State

University campus and the local community. Local physi-

cians, health spas, grocery stores, churches, apartment

complexes, and businesses supported the study by displaying

flyers and placing advertisements In their monthly newslet-

ters or bul letlns. Advertisements were also placed In the

New River Valley Section of The Roanoke Times and The Spec-

36

trum. Individuals Interested In the study were asked to

telephone the Investigators for further information. An

attempt was made to recruit women prior to their 12th week

of gestation; however, women were recruited up unti I the

20th week of gestation.

Screening 1u. Subjects The subject's responslbl I !ties and the purpose of the

study were described to al I interested Individuals during

the Initial telephone conversation. Gestational

determined by the number of weeks since the first

age

day

was

of

each woman ' s I as t mens tr u a I per Io d • The first appointment

was scheduled to correspond to the 12th week of pregnancy or

the closest week which was a multiple of four thereafter.

During her first visit each participant received an oral and

written (Appendix J) explanation of the study. Potential

risks of the study and monetary compensation were describ-

ed, confidential lty was assured and any questions were an-

swered. Upon acceptance as a participant, each subject was

asked to give her written, Informed consent of participation

(Appendix K) and was assigned to one of two Investigators.

An attempt was made to have the same examiner perform each

set of measurements on a subject throughout the study.

Initially, subjects were el lmlnated from the study If they

were found to have diabetes, high blood pressure, If they

were less than 20 years or greater than 38 years of age, or

37

if they smoked cigarettes, consumed alcohol and/or recre-

ational drugs habitually. In retrospect, a subject's data

set was eliminated from analysis due to neonatal morbidity

or mortality, multiple pregnancy, del Ivery prior to 37 weeks

or after 42 weeks of gestation, or If they were unable to

keep al I scheduled appointments.

Procedures i.OJ'.:. Obtaining Anthropometric Measurements

Height

Height was measured with the measuring bar. attached to

a standard beam scale at the initial visit only. The sub-

ject, dressed in a paper examining gown and without shoes,

was told to stand straight, with her weight evenly distri-

buted between her feet, with her heels together, her shoul-

ders relaxed and sloping forward and looking straight ahead.

The measuring bar was brought to the top of her head and

pressure was app I I ed to ensure that ha Ir vo I ume was not

measured. The rule was read to the nearest 0.05 cm.

Weight

Weight was measured at each visit with a cal lbrated

single beam scale. Weight was taken after the subject had

voided and with the subject dressed in a paper examining

gown and undergarments. The scale was read to the nearest

0.01 kg.

38

Skinfold Thickness Sklnfold thicknesses were taken at each visit as des-

crlbed by Getchel I (1983). A fold of non-muscular tissue

was grasped with the left thumb and forefinger of the inves-

tlgator at each designated site. A Lange Skinfold Caliper

(Cambridge Scientific Instruments, Cambridge, MD), cali-

brated, and with a standard pressure of 10 g/mm, was placed

approximately 1 cm below the grasped point at a depth equal

to the thickness of the fold. Each sklnfold was measured on

the dominant side of the body, in the vertlcle plane whl le

the subject stood at ease, except for the subscapular and

supra I I lac measurements which were taken fol lowing the natu-

ral fold of the skin. Skinfold measurements were performed

In trip I lcate and the average of the three values was

recorded to the nearest 0.5 mm. Sklnfold measurements were

taken at the fol lowing anatomical sites:

Triceps: at the midpoint of the back side of the upper arm, as determined by measuring the distance between the ol lcran-on and the ulnar process with the elbow bent at a 90 degree angle. The midpoint was marked with a pen and the skinfold grasped approximately 1 cm above the designated point. The measurement was taken while the arm hung straight and next to the body.

Subscepuler: at the bottom of the shoulder blade.

Mfdexll lery: at the middle of the side, level with the lower end of the sternum.

Suprell lee: at the crest of the I I tum, at the middle to the side of the body.

Abdomena approximately 2 cm to the side of the navel.

39

Mid-thigh: at the middle of the front of the thigh, midway between the hip and the knee.

Knee: midi lne, 2 cm above the top of the pate I la.

Mid-calf: mldline, 5 cm below the crease behind the knee.

CJccumference Circumference measurements were taken at each visit

with a metal tape measure (Tip Top, Wyteface, Keuffel &

Esser Co.). Measurements were taken on the dominant side of

the body, where appropriate, wh 11 e the subject stood ta I I

and relaxed and with her weight evenly distributed between . her feet. The tape measure was held In contact with the

skin, without constriction. Each measurement was read once

and to the nearest 0.1 cm. Measurements were taken at the

following sites (Getchell, 1983):

Bust: at the nipple-line and at the midpoint of a normal breath.

Waist: at the minimal abdominal girth, below the rib cage and just above the top of the hip bone. The subject placed the tape measure at her waist at each visit.

Hips: at the maximal protrusion of the buttocks.

Mid-thigh: at the maximal circumference just below the gluteal fold.

Mid-calf: at the maximal circumference.

Ankle: at the minimal circumference, just above the ankle bone.

Upper Arm: at the midpoint as described for triceps sklnfold measurement.

Wrist: at the minimal circumference just above the ulnar process.

40

Blood Pressure Blood pressure was taken at each visit on the right arm

as the subject sat in an upright position. A sphygmomano-

meter and a stethoscope were used. The blood pressure cuff

was secured on the subject's right arm above the elbow and

pumped to at least 160 mm Hg. The stethoscope was placed on

the crease of the right elbow. The pressure was released

slowly and the systolic value was recorded as the pressure

at which the initial sound was heard. The diastolic value

was recorded as the pressure at which the sound disappeared.

UrJne Analysts Urine samples were collected at the beginning of each

appointment In a disposable plastic specimen cup. Each sam-

ple was tested with a Bi I !-Lab Stlx Reagent Strip (Ames

Division, Miles Laboratories, Indiana) within 15 minutes of

voiding. One reagent strip was removed from the bottle and

the reagent areas were completely immersed in urine. The

strip was removed Immediately after moistening to avoid dis-

solving the reagents. The edge of the strip was touched to

the side of the container to remove excess urine and then

held In a horizontal position to prevent the chemicals In

different test areas from mixing. pH, protein, glucose and

ketone (acetoacetlc acid) concentrations were measured by

comparing the test areas to color-coded charts on the bottle

label at the times specified by the manufacturer.

41

a.a..d.-¥ f..a..:t .a..ru1 Percent a.a..d.-¥ f..a..:t

Body fat and percent body fat were calculated In retro-

spect, for each Individual, at each measurement period. The

following equations were used (Sloan, 1962):

Body fat (mm) = triceps skinfold (SF) + subscapular SF+ supra I I lac SF+ mldaxl I lary SF+ abdominal SF+ thigh SF

Body density Cg/cc 3 ) = 1.0764 - C0.00088 x triceps SF (mm)) - 0.0081 x supra I I lac SF

Percent body fat= [(4.57/body density) - 4.143] x 100

1Z J::lQ.u.c Record Each subject was presented with a 72 hour food record,

an example of a completed food record, and written (Appendix

L) and oral instructions on how to complete the food record.

A food record was kept for three consecutive days prior to

each visit. It was suggested that holidays and "atypical"

days be excluded from the record. Subjects were instructed

to record everything they consumed In terms of the exact

food Item eaten, the amount of each food consumed and how

the food was prepared. Each food record was submitted to

the Investigator at the beginning of each appointment. The

Investigator reviewed the record upon receipt and clarified

any questionable enteries. Dietary Information obtained

through the food records was coded using the Nutritional

Analysis System of The Department of Experimental Statis-

tics at Louslana State University. Food records were ana-

lyzed to determine dally and three day averages of caloric

42

and nutrient content and percentages of the recommended

d I etary a I I owances consumed.

Stcttsttcal Analysts

The mean and standard deviation (SD) were determined

for each measurement, body fat and percent body fat at each

measurement period between 12 to 40 week~ of gestation for

both normal weight and overweight gravldas. Genera I Ii near

regression analyses were performed to determine the best fit

curve for the mean values for each measurement of the normal

and overweight groups throughout the third trimester alone

(weeks 26 to 40) and also over the second and third trimes-

ters (weeks 12 to 40). T-tests were performed to test for

significant difference (p < 0.05) between: (1) the observed

slope of the curves and zero and (2) the observed slope of

the curves between the normal weight and overweight groups

for each measurement.

Multiple I !near regression tests {Maximum R Squared

Improvement For Dependent Variables and Backward El !mi nation

Procedure For Dependent Variables) were performed to deter-

mine the predictive value of maternal prepregnant weight,

pregnancy weight gain, percent desirable prepregnant weight

for height, maternal age, body fat and percent body fat on

blrthwelght of the Infant.

Food records were analyzed for the mean of total calor-

ies, protein Cg), fat Cg) and carbohydrate (g) and the mean

43

percentage of recommended dietary allowance (RDA) of calor-

ies and protein consumed. The percentages of total calories

as protein, fat and carbohydrate were calculated. T-tests

were performed to test for significant difference between

the normal weight and overweight groups during the third

trimester (weeks 28 to 40 of gestation) and the second and

third trimesters (weeks 12 to 40).

RESULTS

Fifty-one healthy, Caucasian, pregnant females 20 to 30

years of age (mean: 27.9 +/- 4.15 years) participated in the

study. A summary of the demographic information Is

presented In Table 3.

about the minor urban

100,000) of Blacksburg,

In general,

community

Virginia.

the women I ived In or

(population: 25,000-

They exhibited a ml Id

activity level and had at least a high school education.

The majority of women were employed outside of their homes

and the average annua I gross tam 11 y Income was $24, 373.

Participants were divided Into two groups according to

percent desirable prepregnant weight for height. Seventeen

women exceded 110 percent desirable prepregnant weight for

height and were considered overweight (mean weight: 66.87

+/- 6.83 kg). Twenty-eight women were within 85 to 110

percent desirable prepregnant weight for height and were

considered normal weight (mean weight: 55.11 +/- 4.53 kg).

The data sets of four participants were excluded from analy-

sis due to premature delivery(< 37 weeks gestation). The

data set of a fifth participant was omitted from analysis

due to multiple gestation.

The mean and standard deviation of weight (Table 4),

skinfold (Table 5) and ·circumference (Table 6) measurements

and body fat and percent body fat (Table 7) were calculated

and tested for significant difference between the overweight

44

45

TABLE 3. Description of overweight and normal weight subjects.

Maternal Characteristic Overweight N=17

Age Cyr)

Mean+/- SD: Range: 20 to 38

20-25 26-30 31-35

> 36

Parity

Range: 1 to 3

1 2 3

Percent Desirable Weight For Height

Mean+/- SD: Range: 85.0 to

< 90 90-100

100.1-110 110.1-120 120.1-130 130.1-140 140.1-150

> 150

25.8 +/- 7.5

Prep regnant

1 21 • 90 151 • 2

5 7 5 0

8 8 1

0 0 0

10 4 1 1 1

+/- 11.46

Normal Weight N=28

26.3 +/-

1 0 1 1

6 1

7 14

7

99.30

2 1 5 1 1

0 0 0 0 0

6.9

+/- 5.26

46

Table 4. The mean values*for weight Ckg) gestation for normal weight and

Week

12 1 15 2 1 6 26 20 29 24 29 28 29 32 29 36 28 40 1 5

1 +/- 2 weeks 2 N

Normal Weight

54.79 +/- 3. 1 53 57.65 +/- 4.79 59.53 +/- 4.77 61 • 43 +/- 5. 12 63.05 +/- 5.05 64.85 +/- 5.30 66.06 +/- 5.39 68.06 +/- 5.55

3 mean+/- standard deviation

72 14 17 1 7 17 1 7 17 12

at each week of overweight gravldas.

Overweight

64.76 +/- 3.40 3 69.64 +/- 5.92 71 • 61 +/- 5.86 73.49 +/- 6. 1 1 75.57 +/- 5.78 77.72 +/- 6. 1 0 79.78 +/- 6.71 79.73 +/- 5.61

*Values were slgnlftcantly different Cp<0.001) between normal weight and overweight gravldas at each week of gestation.

47

Table 5 • The mean sklnfold measurements (mm) at each week of gestation for normal weight and overweight gravidas.

Site Week 1 Normal Weight Overweight

Triceps 1 2 14 2 1 8. 21 +/- 5.58 3 72 26.00 +/- 4.921 ** 1 6 25 1 8. 1 8 +/- 5.03 1 4 24.89 +/- 5.65 * 20 28 18.96 +/- 4.23 1 7 25. 1 2 +/- 6.39 ** 24 29 18.78 +/- 4.07 1 7 25.62 +/- 6.41 * 28 29 19.37 +/- 4.23 1 7 25.97 +/- 6.59 ** 32 29 19.07 +/- 4.32 1 7 26.10 +/- 7.60 ** 36 28 18.37 +/- 4.23 1 7 26. 1 8 +/- 6.67 ** 40 1 5 18.60 +/- 3.73 12 24.46 +/- 7.70 ***

Sub scapular 12 1 5 14.87 +/- 5.33 7 1 9. 7 1 +/- 3.39 *** 1 6 24 14.57 +/- 4.25 1 2 22. 1 7 +/- 7.37 * 20 28 14.84 +/- 4.01 1 7 22.68 +/- 6.87 * 24 28 14.50 +/- 3.28 1 6 23.31 +/- 6. 5 0 * 28 28 15.00 +/- 4.03 1 6 21 • 97 +/- 5.32 * 32 29 1 5. 1 4 +/- 4.68 1 7 24.78 +/- 6.20 * 36 28 14.68 +/- 4. 1 9 1 7 23.38 +/- 5.84 * 40 1 5 14.40 +/- 4. 3 6 12 24.04 +/- 7.77 **

Supra Iliac 1 2 12 24.88 +/- 6.77 7 32.79 +/- 3.83 ** 1 6 24 27.94 +/- 7.99 1 3 3 5. 1 9 +/- 6.06 ** 20 29 29.07 +/- 6.51 17 37.21 +/- 6.65 * 24 28 31 • 43 +/- 7.05 1 7 36.50 +/- 6.06 *** 28 28 30.91 +/- 5.83 1 7 37.38 +/- 6.01 * 32 28 29.75 +/- 5.69 1 7 38.20 +/- 4.41 * 36 27 29.87 +/- 5.62 17 37.79 +/- 5.02 * 40 1 5 29.67 +/- 6.77 1 2 3 5. 1 7 +/- 6.95 ***

Midaxl I lary 12 1 1 12. 41 +/- 3.88 6 14.67 +/- 2.56 1 6 24 1 3 • 1 4 +/- 4.02 14 21 • 4 0 +/- 8. 1 8 ** 20 28 1 3 • 2 1 +/- 3.32 1 7 21 • 3 0 +/- 8.28 ** 24 28 13.45 +/- 2.62 1 7 21 • 5 6 +/- 7.30 * 28 29 13.38 +/- 2.81 1 7 20.91 +/- 6. 91 * 32 29 13.36 +/- 3.29 1 6 22.47 +/- 7 • 1 1 * 36 26 13.83 +/- 4.22 1 7 21 • 91 +/- 6.82 * 40 1 5 14.07 +/- 5.29 1 1 22.41 +/- 9.35 ***

Abdominal 12 1 5 18.23 +/- 7.27 7 20.86 +/- 6. 1 6 1 6 24 18.79 +/- 6.62 1 4 27.07 +/- 8.25** 20 29 18.42 +/- 5.92 1 7 25.00 +/- 7.74** 24 28 17.32 +/- 5.00 1 7 21 • 00 +/- 7.45 28 29 13.91 +/- 5.34 1 7 1 6. 91 +/- 6.73 32 29 11 • 2 2 +/- 5.90 1 7 13.32 +/- 5.47 36 27 8.78 +/- 5.06 1 6 10.53 +/- 4.36 40 1 3 6.15 +/- 3.85 12 7.67 +/- 5. 1 2

Table 5. cont.

Site Week1

Thigh 12 1 6 20 24 28 32 36 40

Knee 12 1 6 20 24 28 32 36 40

Calf 12 1 6 20 24 28 32 36 40

1 +/- 2 weeks 2 N

14 2 26 29 29 29 29 27 1 5

15 25 29 28 29 29 28 1 5

15 23 28 29 29 28 28 1 5

48

Normal weight

28.57 +/- 6. 7 ( 28.51 +/- 5. 51 29.07 +/- 5.69 29.55 +/- 6.31 29.17 +/- 5.74 29.67 +/- 5.74 28.65 +/- 6.35 26.67 +/- 7.44

21. 43 +/- 5. 13 22.08 +/- 4.46 22.02 +/- 4.44 22.75 +/- 4.98 21 • 07 +/- 5.74 20.83 +/- 6.68 19.80 +/- 6.35 18.53 +/- 5.45

20.10 +/- 5.20 21. 30 +/- 5.55 20.93 +/- 6.32 20.41 +/- 6". 26 20.38 +/- 4.51 18.73 +/- 4.95 16.98 +/- 4.43 16.40 +/- 4.55

3 mean+/- standard deviation

Overweight 72 34.50 +/- 6. 083

1 4 35.32 +/- 8.09 17 34.85 +/- 6.47 1 6 34.88 +/- 7.87 1 6 34.56 +/- 6.30 1 5 36.43 +/- 7.73 1 7 34.82 +/- 7.76 12 35.83 +/-10.18

7 28.50 +/- 8.47 13 26.80 +/-10.02 17 28.03 +/- 8.81 1 6 26.09 +/- 9.11 17 24.03 +/- 9.94 1 7 26.09 +/- 9.41 17 25.35 +/- 9.62 12 25. 13 +/-10.22

7 23. 1 4 +/- 7.65 14 25 .12 +/- 9. 1 5 1 6 20.78 +/- 8.62 1 6 21. 38 +/- 7. 7 8 17 19.74 +/- 5.23 1 7 20.21 +/- 4.84 17 18.47 +/- 5.86 12 17.83 +/- 6.53

Values significantly different between normal weight and overweight gravldas:

* p<0.001 ** p<0.01 *** p<0.05

** ** *** ** ** ** ***

***

***

*** ***

49

Table 6. The mean circumference measurements (cm) for each week of gestation for normal weight and overweight gravldas.

Site Week 1 Normal Weight Overweight

Bust 12 142 85.53 +/- 4. 96 3 7 2 93.42 +/- 4.59 3** 1 6 26 87.63 +/- 3.94 14 96.81 +/- 5.51 * 20 29 88.52 +/- 3.79 1 7 98.04 +/- 4.92 * 24 29 89.68 +/- 3.97 1 7 99.52 +/- 4.88 * 28 29 91 • 90 +/- 4.36 17 100.80 +/- 5. 1 0 * 32 29 92 .13 +/- 4.57 1 7 101.51 +/- 5.38 * 36 28 92. 19 +/- 4.61 17 101.94 +/- 5. 1 7 * 40 1 5 93.58 +/- 5.99 12 102.93 +/- 5.49 *

Waist 12 15 71 • 84 +/- 4.09 7 76.93 +/- 4.18 *** 1 6 26 74.82 +/- 4.08 14 83.57 +/- 5.29 * 20 29 77.66 +/- 4.67 17 86.39 +/- 4.06 * 24 29 82.44 +/- 5.25 1 7 90.43 +/- 4.51 * 28 29 85.57 +/- 4.86 17 94.09 +/- 4.27 * 32 29 88.69 +/- 4.88 1 7 97.45 +/- 5.20 * 36 28 92.44 +/- 4.87 17 101.42 +/- 5.23 * 40 1 5 95.19 +/- 5.63 12 101. 78 +/- 4.76 *

Hips 12 14 91 • 5 0 +/- 3.45 7 99.70 +/- 4.63 ** 1 6 26 94.04 +/- 3.48 14 101. 10 +/- 4.43 * 20 29 94.83 +/- 3.55 1 6 102.38 +/- 4.25 * 24 28 96.58 +/- 3.51 1 6 103.14 +/- 4.29 * 28 29 96.69 +/- 4.21 1 6 103.28 +/- 3.86 * 32 28 97.50 +/- 3.86 1 7 104.38 +/- 3.94 * 36 28 97.62 +/- 4.03 17 105.21 +/- 4.89 * 40 1 5 97.97 +/- 3.62 12 105.36 +/- 5. 1 0 *

Thigh 12 14 52.53 +/- 3.20 7 57.90 +/- 2.02 *** 1 6 26 53.59 +/- 3.82 14 58.31 +/- 4.23 * 20 28 53.93 +/- 3.79 17 58.54 +/- 3.29 * 24 28 54.48 +/- 4.61 1 6 60.15 +/- 3.25 * 28 29 54.60 +/- 4.37 17 60.47 +/- 3. 1 4 * 32 29 54.82 +/- 4.46 1 7 60.29 +/- 3.35 * 36 27 54.75 +/- 4. 12 17 60.26 +/- 3.26 * 40 15 55.05 +/- 3.75 12 59.50 +/- 3.96 **

1 +/- 2 weeks 2 N 3 mean+/- standard deviation

Values significantly different from zero: * p<0.001 ** p<0.01 *** p<0.05

50

Table 6. cont.

Site Week 1 Normal Weight Overweight

Calf 1 2 1 52 33.27 +/- 1 • 7 8 3 7 2 36.37 1 6 20 24 28 32 36 40

Ankle 12 1 6 20 24 28 32 36 40

Upper 12 Arm 1 6

20 24 28 32 36 40

Wrist 12 1 6 20 24 28 32 36 40

1 +/- 2 weeks 2 N 3 mean+/- SD

26 29 29 29 29 28 1 5

1 5 26 28 29 29 29 28 1 5

14 26 29 29 29 29 28 1 5

1 5 26 29 29 29 29 28 1 5

33.84 +/- 1 • 7 1 1 4 34.07 +/- 1 • 97 1 7 34. 12 +/- 1 • 90 1 7 34.31 +/- 1 • 83 17 34.59 +/- 1 • 92 1 7 34.81 +/- 1 • 90 1 7 34.89 +/- 1 • 68 12

20.41 +/- 1 • 1 0 7 20.73 +/- 1 • 4 5 1 4 20.64 +/- 1 • 26 1 7 20.75 +/- 1 • 28 1 7 20.64 +/- 1. 18 1 7 20.67 +/- 1 • 1 7 1 7 20.55 +/- 1. 27 1 7 20.69 +/- 1 • 3 7 12

24.84 +/- 1 • 3 8 7 24.94 +/- 1 • 48 1 4 25.06 +/- 1.55 1 7 25.23 +/- 1. 53 1 7 25.27 +/- 1 • 43 17 25.41 +/- 1.52 1 7 25.36 +/- 1 • 48 1 7 25.33 +/- 1 • 1 9 12

14.77 +/- 0.67 7 15.04 +/- 0.63 14 15.00 +/- 0.76 17 14.98 +/- 0.71 1 7 14.97 +/- 0.73 17 15.01 +/- 0.86 1 7 14.95 +/- 0.76 1 7 1 5 • 1 3 +/- 0.74 12

Values significantly different from zero: * p<0.001 ** p<0.01 *** p<0.05

37.36 37.55 37.34 37.47 38.03 38.35 38.03

21 • 5 7 21 • 88 22.19 22.08 22. 16 22.31 22.33 22.33

28.59 28.83 28.97 28.95 29.29 29.30 29.32 28.84

15.60 15.80 1 6. 1 0 15.98 15.85 16.06 1 6. 1 7 16.06

+/-+/-+/-+/-+/-+/-+/-+/-

+/-+/-+/-+/-+/-+/-+/-+/-

+/-+/-+/-+/-+/-+/-+/-+/-

+/-+/-+/-+/-+/-+/-+/-+/-

1.81 3** 2.41 * 2. 1 5 * 2.34 * 2.49 * 2 .36 * 2.09 * 1 • 91 * 0.91 ** 0.98 ** 1 • 23 * 1. 31 ** 1.32 * 1 • 3 6 * 1.20 * 1 • 03 ** 2.42 * 1 • 97 * 2.08 * 1 • 96 * 2.26 * 2.40 * 2.46 * 1. 96 * 0.93 * 1 • 08 *** 1 • 27 ** 1. 11 ** 1 • 1 6 ** 1.28 ** 1 • 1 7 * 1 • 0 6 ***

51

TABLE 7. The mean body fat (mm) and percent body fat at each week of gestation for normal weight and over-weight gravldas.

Indices Week 1 Normal Weight Overweight

Body Fat 12 8 2 115.13 +/- 32.253 62 144.5 +/- 12.30**3 1 6 20 115.51 +/- 25.91 1 1 153.7 +/- 26.28* 20 26 122.25 +/- 21 • 71 17 166.24 +/- 33.16* 24 25 124.57 +/- 20.35 1 5 161. 90 +/- 31.80* 28 27 122.47 +/- 18.49 15 155.80 +/- 23.36* 32 28 119.40 +/- 17.63 14 159.14 +/- 22.26* 36 25 114.80 +/- 20.32 1 6 155.84 +/- 25.00* 40 13 107.80 +/- 19.35 1 1 152.91 +/- 33.43*

Percent Body Fat 12 1 1 24.09 +/- 8.11 7 37.72 +/- 7.72***

1 6 23 26.53 +/-11.73 13 39.84 +/- 13.81*** 20 28 27.28 +/- 8.42 17 43.67 +/- 16.37** 24 28 29. 13 +/- 8.93 1 7 43. 1 9 +/- 14.78** 28 28 29.12 +/- 7.57 17 44.66 +/- 14.43** 32 28 27.81 +/- 6.63 17 46.23 +/- 15.68** 36 27 27.29 +/- 7.01 17 45.55 +/- 15.80* 40 1 5 27.36 +/- 8.17 12 41. 23 +/- 19.28***

1 +/- 2 weeks 2 N 3 mean+/- standard deviation

Values slgnlflcantly different between normal weight and overweight gravldas:

* p<0.001 ** p<0.01 *** p<0.05

52

and normal weight groups at eight four week Intervals during

gestation, the third trimester <weeks 26 to 40) and the

second and third trimesters {weeks 12 to 40). Information

pertaining to the second trimester, weeks 12 to 26 of gesta-

tion, was described previously {De La Torre, 1986).

The overweight women were significantly heavier

{p<0.001) than the normal weight women at each week of

gestation.

overweight

Skinfold thickness was generally greater among

women with the exceptions of the calf measure-

ments, the Initial mldaxl I lary and thigh measurements; abdo-

minal measurements at week 12 and after week 20; and knee

measurements at weeks 16, 24, 28 and 40. Circumference

measurements, body fat and percent body fat were signifi-

cantly greater among overweight gravldas at each week of

gestation.

Linear equations were flt to each set of mean values

for overweight and normal weight groups during the third

trimester {Table 8). The average rates of change {B 1 ) In

weight, circumference and sklnfold measurements were not

significantly different (p < 0.05) at any site between the

overweight and normal weight groups. Significant Increases

In weight (1.58 kg/four weeks; p < 0.001) and waist cir-

cumference (p < 0.001) and significant decreases In calf (p

< 0.01) and abdominal (p < 0.01) skinfold thicknesses were

demonstrated throughout the third trimester. Appreciable,

although not significant, Increases In bust and hip clrcum-

53

Table 8. Slope and Intercepts of I I near equations flt to the observed mean values of each measurement during the third trimester for normal weight and overweight gravldas.

L i n ea r mode I : Y = B0 + C B1 x X )

Eb= Slope= Linear Coefficient BJ. = Y-1 ntercept

Y-lntercept Measurement Slope CB 1 ) Normal Weight

Weight (kg)

Sklnfold

1 1.58 +/- 0.41** 55.24

Th I ckness (mm)

Triceps -3.46 +/- 4.04 21.1 Subscapular 0. 15 +/- 3.83 14.8 Suprall lac -5.74 +/- 4.23 33.7 Mldaxll lary 2.21 +/- 4.40 12.2 Abdominal -27.64 +/- 4.04** 27.9 Thigh -3.32 +/- 5. 15 30.9 Knee -3.72 +/- 5.72 22.6 Calf -11.94 +/- 3.70* 25.9

Circumferences (cm)

Bust 6.47 +/- 3.64 87.8 Waist 30.68 +/- 3.67** 70.5 Hips 5.60 +/- 3.08 93.8 Thigh -0.23 +/- 2.91 54.9 Calf 2. 19 +/- 1.49 33.2 Ankle 0. 14 +/- 0.91 20.5 Upper arm -0.32 +/- 1.34 25.5 Wrist 0.46 +/- 0.70 14.7

Body fat Cmm)-33.90 +/-16.86 138.6

Percent Body fat -8.57 +/- 8.53 33.4

1 mean+/- standard deviation

Values slgnlflcantly different from zero: ** ( p < 0.001 ) *· (p < 0.01 )

c Eb > Overweight

68.02

28.0 23.5 41 • 1 20.6 30. 1 37.4 27.5 26.9

97.7 78.9

100.9 60.2 36.6 22.2 29.4 15. 8

178.2

50.3

54

ference were also demonstrated. Skinfold thicknesses at the

triceps, subscapula, suprall iac, mldaxl I lary, thigh and

knee; circumference measurements at the thigh, calf, ankle,

upper arm and wrist; body fat and percent body fat remained

the same during the third trimester.

Table 9 describes the I !near and quadratic coeffi-

cients and Intercepts of the equations which best flt the

observed mean values for each measurement during the second

and third trimesters. Graphs of the estimated regression

equations may be found in Appendixes M1 through M19 • The

average rate of change In weight and circumference and

sklnfold measurements were not significantly different bet-

ween the overweight and normal weight groups at any site

except for the abdominal skinfold measurement (p<0.05).

Linear equations were fit to weight; triceps, subscapula,

midaxi I lary, thigh and calf (overweight) skinfold thicknes-

ses; and bust, waist, hip (overweight), thigh (normal

weight), calf (overweight), upper arm, and wrist circumfer-

ences. Quadratic equations were fit to supra I I lac, abdomin-

al, knee (normal weight) and calf (normal weight) skinfold

thicknesses; hip (normal weight) and thigh (overweight) cir-

cumferences; and body fat (normal weight) and percent body

fat (normal weight) indices. Linear or quadratic models did

not flt knee (overweight) skinfold thickness, ankle circum-

ference, or body fat (overweight) and percent body fat

55

Table 9. Linear and quadratic coefficients and Intercepts of equations flt to the observed mean values of each measurement for normal weight and over weight gravldas during the second and third trimesters of pregnancy.

Li near Mode I: Y = 80 + [81 x X]

Quadratic Model: Y = + [Bl x X] + [82 x w2 ]

8 0 = Y-lntercept 8 1 = Linear coefficient 8 2 = Quadratic coefficient

Coefficient Y-1 ntercept C 80 )

Measurements Bl

Weight {kg) 1 • 87 *

Skinfold Thickness {mm) Triceps 0.459 Subscapular 0.1584 Supra Iliac 2.98 Mldaxlllary 2.75 Abdominal -0.084*

Thigh Knee

Calf

0.5923* -0. 1 0

NS 0.9376**

-0.9126*

Circumference Bust

0.9281* {cm) 1 • 0958* 3.478* 0.758* 2.142*

Waist Hips

Thigh

Calf Ankle Upper arm Wrist Body fat

% Body fat

1 • 48 7 0.2928

2.04* NS

0.0744 0.0268

NS 9.1552

NS 26.28

-0.2816

-0.302 -0.2852

-0.154

-0. 1788

Normal

53.56

18.54 14.05 22.95 1 2. 1 2

18.68 28.94

20.77

19.77

85. 1 9 67.94

-0.1468 88.95 -o. 1 262

52.96 33.34 20.65 24.86 14.86

-1.0895 104.14

-2.60 22. 11

Values slgnlflcantly different from zero: * {p<0.001)

** {p<0.01)

Overweight

65.87

25.35 22.24 30.05 20.03 26. 1 2

35.20 26.09

24.98

94.63 7 6. 1 2 99.73

55.92

36.69 22.15 28.70 15.86

157.65

43.32

Appendix

Mg

M14 M15 M16 M17 M1a

Ml9

56

(overweight) indices.

Food consumption data were analyzed for total calories,

protein Cg), carbohydrate Cg), fat Cg) and percentages of

the recommended daily allowances<% RDA) of calories and

protein. Comparison of nutrient intake was made between the

overweight and normal weight gravldas at each week of gesta-

tion (Tables 10-12), the second trimester (Table 13), the

third trimester (Table 13) and the second and third trimes-

ters (Table 14). Caloric intake, fat Cg), carbohydrate Cg)

and the % RDA for calories were significantly different

(p<0.01) and total protein and the% RDA for protein were

marginally different Cp<0.06) between the two groups during

the 28th week of gestation only. The mean caloric intake

for normal weight and overweight gravldas was 2324.51 +/-

613.12 and 2364.60 +/- 593.42 respectively during the second

trimester; 2286.18 +/- 632.97 and 2445.54 +/- 570.79, respe-

ctlvely

2414.41

during the third trimester and 2302 +/- 622.89

+/- 577.67 respectively, during the second

and

and

third trimesters. The mean caloric Intake, the mean gram

values for protein, fat and carbohydrate and the% RDA for

total calories and protein were not significantly different

between the two weight groups within the second or third

trimesters or between the second and third trimesters. In

general, the mean caloric Intake of overweight and normal

weight gravidas was the same throughout the second and third

trimesters.

57

Table 1 0 • Caloric Intake of normal weight and overweight gravldas.

Measure Normal Weight Overweight

Total 1 6 1 2263.36 +/- 814.88 2 2235.71 +/- 867.91 2 Calories 20 2422.48 +/- 616.82

24 2319.44 +/- 476.82 28 2155.46 +/- 545.62 32 2311.50 +/- 546.83 36 2337.24 +/- 830.96 40 2390.71 +/- 547.02

% RDA 1 6 98.41 +/- 35.43 20 105.32 +/- 26.82 24 100.67 +/- 20.71 28 93.71 +/- 23.72 32 100.50 +/- 23.78 36 101 • 62 +/- 36. 13 40 103.95 +/- 23.78

1 Week of gestation+/- two weeks. 2 Mean+/- standard deviation.

2451.46 +/- 626.64 2349.47 +/- 424.56 2609.60 +/- 499.7':f 2344.27 +/- 593.33 2364.00 +/- 585.00 2471.09 +/- 635.45

97.21 +/- 37.73 106.59 +/- 27.25 102.15 +/- 18.46 113.46 +/- 21 • 733 101.96 +/- 25.74 103.38 +/- 26.47 107.44 +/- 27.63

3 Values slgnlflcantly different (p<0.01) between normal weight and overweight gravldas.

58

Table 11. Protein intake of normal gravldas.

Measure Normal Weight

Total 1 61 92.95 +/- 38.96 2 Protein 20 92.39 +/- 26.94

24 85.85 +/- 22.27 28 83.21 +/- 20.64 32 84.49 +/- 20.49 36 86.20 +/- 33.86 40 82.71 +/- 14.85

% RDA 1 6 125.63 +/- 52.64 20 124.86 +/- 36.42 24 116.06 +/- 3 0. 1 1 28 112.45 +/- 27.91 32 114.18 +/- 27.67 36 116.50 +/- 45.77 40 118.18 +/- 29.82

1 Week of gestation+/- two weeks. 2 Mean+/- standard deviation.

weight and overweight

Overweight

77.83 +/- 24. 57 2 96.88 +/- 27.90 88.43 +/- 23.24 9 8. 1 3 +/- 28.67 3 91 • 28 +/- 22.79 90.89 +/- 21 . 21 96.46 +/- 28.35

105.18 +/- 33.22 130.93 +/- 37.70 119.49 +/- 31 • 43 132.60 +/- 3 8. 7 23 123.36 +/- 30.79 122.81 +/- 28.68 130.37 +/- 38.31

3 Values marginally different (p<0.06) between normal weight and overweight gravidas.

59

Table 1 2 • Total fat and carbohydrate consumption of normal overweight gravldas.

Measure Normal Weight Overweight

Total Fat ( g) 1 6 1 101.04 +/- 3 7. 732 76.34 +/- 3 9. 1 52 20 109.54 +/- 35.65 24 101.34 +/- 24.98 28 90.69 +/- 33.98 32 102.49 +/- 30.26 36 106.04 +/- 49.39 40 103.00 +/- 36.04

Total Carbohydrate ( g) 1 6 259.52 +/- 97.91

20 280.85 +/- 77.29 24 280.85 +/- 67.97 28 262.55 +/- 62.94 32 277.95 +/- 74.62 36 272.90 +/- 92.85 40 298.39 +/- 70.39

1 Week of gestation+/- two weeks. 2 Mean+/- standard deviation.

104.27 +/- 37.65 102.82 +/- 22.81 108.08 +/- 27. 943

96.81 +/- 37.10 96.21 +/- 31 • 2 5

102.82 +/- 34.66

300.20 +/-112.33 287.35 +/- 72.24 274.83 +/- 58. 793 315.10 +/- 57.63 284.66 +/- 82.40 293.33 +/- 78.18 298.77 +/- 81.49

3 Values slgnlflcantly different between normal weight and overweight gravldas.

60

Table 13. Macronutrlent analysis: mean nutrient Intake values of normal weight and overwei~ht gravldas during the second and third trimesters.

Time Period

Second Trimester

Total Calories % RDA

Total Protein Cg) % RDA

Total Fat Cg)

Total Carbohydrate Cg)

Third trimester

Total Calories % RDA

Total Protein Cg) % RDA

Total Fat Cg)

Total Carbohydrate Cg)

Normal Weight

2324.51 +/- 613.12 2 101.00 +/- 26.65

89.11 +/- 27 .89 120.45 +/- 37.70

103.54 +/- 31.89

273.33 +/- 78.8

2286.18 +/- 632.97 99.40 +/- 27.52

84.32 +/- 23.96 114.94 +/- 33.47

100.17 +/- 38.10

275.31 +/- 76.13

Overweight

2364.60 +/- 593.422 102.81 +/- 25.80

89.45 +/- 25.56 120.88 +/- 34.55

98.06 +/- 33.27

284.55 +/- 74.75

2445.54 +/- 570.79 106.50 +/- 25.05

94.03 +/- 24.75 127.06 +/- 33.44

100.85 +/- 32.27

297.91 +/- 73.97

There were no slgniflc~nt differences (p<0.05) in macronutrlent Intake between normal weight and overweight gravidas.

2 mean+/- standard deviation

61

Table 1 4. Mean macronutrient Intake of normal weight and overweight gravldas between the 12th and 40th weeks of gestation. 1

Measure Normal Weight Overweight

Total Calories 2302.57 +/- 622.89 2 2414.41 +/- 577.67 2

%RDA 100.08 +/- 27.08 105.08 +/-

Total Protein ( g) 86.37 +/- 25.74 92.27 +/-% RDA 117.29 +/- 35.33 124.68 +/-

Total Fat ( g ) 101.61 +/- 35.51 99.77 +/-

Total Carbohydrates ( g ) 274.46 +/- 77.06 292.77 +/-

1 There were no significant differences (p<0.05) In macronutrlent Intake of %RDA between the normal weight and overweight gravldas.

2 mean+/- standard deviation

25.27

25.02 33.81

32.50

74.14

62

The percentage of total calories as protein, fat

and carbohydrate were determined for normal and overweight

gravidas at each four week interval between 16 and 40 weeks

of gestation (Table 15). Dietary composition patterns were

slmi lar between the two groups except during the 16th week

of gestation when the percentage of fat In the diet was

significantly greater (p<0.001) and the percentage of carbo-

hydrate significantly less (p<0.001) among normal weight

gravldas than among overweight gravldas.

Multiple I I near regression tests showed that of pre-

pregnant weight, maternal weight gain, maternal age, percent

deslreable prepregnant weight for height, maternal body fat

and percent body fat, only maternal weight gain was signif i-

cantly correlated (p<0.05) with infant birth weight among

both overweight and normal weight gravladas.

63

Table 1 5 . Percentate of fat, carbohydrate and protein I n diets of normal weight and

Measure Normal Weight

% Fat 1 6 1 40.15 +/- 4. 41 2 20 40.16 +/- 5 .3 6 24 39.33 +/- 5.80 28 37.05 +/- 6.04 32 39.45 +/- 4.89 36 39.87 +/- 7. 1 6 40 37.72 +/- 6.27

% Carbohydrate 1 6 45.85 +/- 5.25 20 46.51 +/- 6.41 24 48.43 +/- 6.85 28 49.04 +/- 5.72 32 48.08 +/- 6.46 36 47.22 +/- 7.45 40 50.49 +/- 7.47

% Protein 1 6 1 6. 5 1 +/- 4. 38 20 15.56 +/- 3.26 24 14.92 +/- 2.64 28 15.78 +/- 3.52 32 14.90 +/- 2.87 36 1 5 • 1 1 +/- 3.61 40 14.28 +/- 2.96

1 Week of gestation+/- two weeks. 2 Mean+/- standard deviation.

overweight gravldas.

Overweight

29.74 +/- 6. 35 2 37.69 +/- 6. 13 39.30 +/- 5. 13 36.99 +/- 5.85 36.78 +/- 8.38 36.10 +/- 5. 51 4 37.08 +/- 6. 1 5

54.55 +/- 8. 06 3 47.25 +/- 5.33 46.94 +/- 6. 1 6 48.86 +/- 6. 1 4 48.53 +/- 7. 13 49.81 +/- 4.88 48.59 +/- 7.27

14.26 +/- 1. 63 15.89 +/- 2.28 15.08 +/- 3. 1 6 14.89 +/- 2.90 15.90 +/- 3.27 15.64 +/- 3.48 15.74 +/- 3. 1 6

the

3 Values significantly different (p<0.001) between normal weight and overweight gravldas.

4 Values marginally different (p<0.1) between normal weight and overweight gravldas.

DISCUSSION

Weight Increased at a rate of 1.58 kg per four week

Interval, or 0.39 kg per week during the third trimester for

both the overweight and the normal weight groups. This

estimate of rate of weight gain during the third trimester

Is sl lghtly higher than the that reported ~y Pitkin (1976):

0.3 kg per week; conslstant with Hyten and Leitch's (1971)

report of 0.36 to 0.41 kg per week; and slgnlffcantly less

than Guerl et al. (1982) report of 0.678 kg per week. The

rate of weight gain across both the second and third trimes-

ters was 1.87 kg per four week interval or .47 kg per week.

The pattern of change of sklnfold measurements was

not slgnlflcantly different between the normal weight and

the overweight groups during the third trimester. The calf

and abdominal sklnfold thicknesses slgnlflcantly decrease In

absolute mean value. The decrease In abdominal sklnfold

thickness corresponds to the Increased waist and hip circum-

ference associated with increased fetal size. The skinfold

at the abdominal site was difficult to grasp due to the

tightness of the skin in that area during the latter part of

the third trimester. T~e decrease In calf sklnfold thick-

ness may be due to the difficulty In assuring that the lower

leg was relaxed when the measurement was taken. If the

muscle In the lower leg Is taut, as when standing tal I with

both feet on the floor, a smaller measurement would result.

64

In

reported

crease In

65

contrast to the change in sklnfold thicknesses

by Taggart (1967), there was no significant In-

thigh sklnfold thickness nor a significant de-

crease In mldaxlllary or triceps skinfold thickness among

either group during the third trimester. Differences Inher-

ent In the two sample populations, the weeks of gestation

that measurements were performed, the methods used to sta-

tistically analyze the data, and the division of women Into

two subgroups according to percent prepregnant weight/height

may contribute to the differences In results (statistical

significance was not reported by Taggart et al.). In addi-

tion, the mean skinfolds and standard deviations reported by

Taggart et al. for the 10th, 20th, 30th and 38th weeks of

gestation were considerably less than the mean skinfolds and

standard deviations I lsted In Table 5 for triceps, subscapu-

lar, and thigh and considerably more for mid-thigh measure-

ment. Measuring technique, the use of different types of

cal lpers, and the difference In philosophy of weight gain

during pregnancy as described by Gormlcan et al. (1980) may

also contribute to the difference In results. Taggart et

al. stated that the Increase of sklnfold thickness during

pregnancy was greater In underweight than In overweight

women. By comparison the women participating In this study

had greater sklnfold measurements than those women reported

by Taggart et al. and therefore would not be expected to

demonstate a similar Increase In sklnfold thickness •.

66

When the change In sklnfold thickness was considered

across both the second and third trimesters a decrease In

abdominal sklnfold thickness was significantly greater among

overweight women than among normal weight women. This may

be explained by the overweight gravldas having a greater

Initial abdominal sklnfold thickness and therefore a larger

amount of fat to be stretched across the lower abdomen as

fetal size Increases.

Changes In circumference measurements during the

second and third trimester occurred predominantly at cen-

tral sites and may be accounted for by Increases In breast

tissue and fetal size. Little change was demonstrated at

peripheral sites with the exception of increased calf

circumference.

Pregnancy Is characterized by the prol Iteration of

breast and uterine tissue In response to Increased levels of

circulating placental estrogens and progesterone. Estrogens

stimulate growth and branching of the ductual system, an

Increase In the quantity of stroma, and fat deposition

within the stroma of mammary tissue. Progesterone induces

growth of the lobules, budding of alveol I and development of

the secretory character of aveol I eel Is In preparation for

lactation. Estrogens and progesterone are also responsible

for the growth, development, and maintenance of the decidual

eel Is of the uterine environment.

67

Caloric and macronutrient consumption were siml lar bet-

ween the overweight and normal weight groups and did not

change throughout the second and third trimesters of preg-

nancy. Both groups consumed at least 90 percent of the

recommended caloric requirement and 105 percent of the re-

commended protein requirement for pregnant women throughout

pregnancy. The percentages of total calories of each macro-

nutrient were also slml lar between the two groups

during the 16th week of pregnancy. The similarity of

except

total

caloric and macronutrient consumption, diet composition and

weight gain patterns between the overweight and normal

weight groups suggest that women In the two weight groups

gain weight at the same rate when caloric and nutrient

Intakes are similar.

Multiple regression analysis was performed to deter-

mine the abll lty of maternal prepregnant weight, weight

gain, percent prepregnant weight for height, age, body fat,

percent body fat and combinations there of to predict Infant

blrthwelght. Maternal weight gain was the only variable

significantly correlated to Infant birth weight in either the

normal weight or the overweight group. Maternal weight gain

was slgnlficantly correlated with infant birth weight for

the overweight group only after two sets of Inconsistent

observations were omitted from the analysis. The prepregnant

weights of the women whose data sets were omitted from

analysis were 151.24 and 128.00 percent of desirable weight

68

for height. Both women would be considered "obese" rather

than overweight by the definition of 120 % standard prepreg-

nant weight for height. In addition one woman del lvered a

low

The

who

birth weight Infant who weighed less than 2500

other woman del lvered an excessive birth weight

weighed 4890 grams. The birth weights of al I

grams.

infant

other

infants born to women participating in the study were within

an optimal range (2500-4500 grams; Table 16).

69

Table 16. Blrthwelght of Infants born to overweight and normal weight subjects.

Birth Weight (kg)

Mean +/- SD: Range: 2.4 to 4.89

< 2.50 2.51-3.00 3.01-3.50 3.51-4.00 4.01-4.50

> 4.50

Overweight N=14

3.52 +/- 0.61

1 2 3 6 1 1

Normal weight N=27

3.53 +/- 0.44

0 2

1 1 8 6 0

pated

SUMMARY AND CONCLUSIONS

Fifty-one healthy caucaslan pregnant women partlcl-

ln a anthropometric study to determine If overweight

women deposit and mobi I lze fat stores differently than nor-

mal weight women during pregnancy. Weight, skinfold thick-

nesses, body circumference measurements and 72 hour food

records were taken at four week intervals betweeen 12 and 40

weeks of gestation. The data sets of each week were analyzed

by week of gestation to determine the change over the second

and third trimesters and the third trimester alone. The two

weight-determined groups showed slmi lar patterns of weight

gain, change In skinfold thickness and body circumference,

and caloric and macronutrlent consumption during the third

trimester. Similar patterns of weight gain were also demon-

strated over the second and third trimesters (1 .87 kg/4 wk).

Changes in abdominal and calf skinfold thicknesses and hips

and thigh circumferences were slgnlflcantly different bet-

ween the overweight and normal weight groups over the second

and third trimesters. In general, the changes In circumfer-

ence occurred at central sites as evldensed by Increases in

bust, waist and hip circumference. The size of subcutaneous

fat stores at the thigh and calf sites are not I lkely to be

influenced by fetal growth (displacement of maternal fat

stores by increased fetal size) or by maternal tissue deve-

lopment (endocrine Induced tissue development). The differ-

70

71

ence In the patterns of change of calf skinfold and thigh

circumference measurements between overweight and normal

weight gravidas may reflect differences In fat storage and

utl I ization at these sites during the second and third

trlmseters of pregnancy.

Maternal weight gain was significantly associated with

infant birth weight In both the normal weight and the over-

weight groups. Maternal age, prepregnant weight, percent

deslreable prepregnant weight for height, body fat and per-

cent body fat were not significantly associated with infant

birth weight. These results support the Importance of

adequate maternal weight gain among both normal weight and

overweight women to enhance the outcome of pregnancy.

LITERATURE CITED

Brown, J. E.,and L. Askue. Differential effects of prepreg-nancy weight and weight gain during pregnancy on Infant growth. Fed. Proc. 1979;38:610.

Brown, J.E., Jacobson, H. N., Askue, L. H. and M. G. Peick. Influence of pregnancy weight gain on the size of infants born to underweight women. Obstet. Gynecol. 1981;67: 13-17.

Calandra, C., Abell, D. obesity in pregnancy.

A., and A. Belscher. Maternal Obstet. Gynecol. 1981;67:8-13.

Committee on Dietary Allowances. Recommended Dietary Al low-ances. Natl. Acad. Sci. Natl. Res. Council, Washington, D. C., 9th ed., 1980.

Committee on Maternal Nutrition. Maternal Nutrition and the Course of Pregnancy. Natl. Acad. Sci., Natl. Res. Council. Washington D. C., 1970.

De La Torre, M. M. Maternal anthropometric measures and nutrient intake during the second trimester of pregnancy of normal weight and overweight sravidas. Thesis. Department of Human Nutrition and Foods. VPl&SU. 1986.

Edwards, L. E., Dickes, W. F., Alton, Pregnancy in the massively obese: obesity prognosis on the Infant. 1978;131 :479-483

I. R., and E. Y. Hakanson. course, outcome and Am. J. Obstet. Gynecol.

Garn, S. M., and S. D. Pesick. Relationship between various maternal body mass measures and size of the newborn. Am J. Cl in. Nutr. 1982;36:664-668.

George, N. N., Kim, S. K. and J. L. Dukrlng. Prepregnancy weights and weight gains related to blrthweights of infants born to overweight women. J.A.D.A. 1984;84: 450-452.

Gatchel I, B. Physical fitness, a way of I ife. John Wiley & Sons, New York, 3rd ed., 1983.

Gormican, A., Valentine, J., and E. Satter. Relationships of maternal weight gain, prepregnancy weight, and birth-weight. J.A.D.A. 1980;77:662-227.

72

73

Gue r i , M. , J u ts um, P. , and B. Sor ha I n do. Ant hr op om et r i c assessment of nutritional status in pregnant women: a reference table of weight-for-height by week of pregnancy. Am. J. Clin. Nutr. 1982;35:609-611.

Harrison, G. G., Udall, J. N. and G. Morrow. Maternal obesity, weight gain In pregnancy, and Infant birth-weight. Am. J. Obstet. Gynecol. 1980;136:411-412.

Himes, J. H., Roche, A. F., and P. Webb. Fat areas as estimates of total body fat. Am. J. Cl in. Nutr. 1980;33:2093-2100.

Hytten, F. E., and I. Leitch. The physiology of human pregnancy. Blackwel I Scientific Publ icatlons, Oxford, 2nd ed., 1971.

Lechtig, A., Yarbrough, C., Delgado, H., Habicht, J.P., Martorelli, R., and R. Klein. Influence of maternal nutrition on birth weight. Am. J. Cl in. Nutr. 1975; 28:1223-1233.

Luke, B. Maternal Nutrition. Little Brown, Boston, 1st ed., 1979.

Luke, B, Jonaitis, M.A., and R.H. Petrie. A consideration of height as a function of prepregnancy nutritional background and Its potential influence on birthweight. J.A.D.A. 1984;84:176-181.

Luke, B., and R. H. Petrie. Intrauterine growth: correla-tion of Infant birth weight and maternal postpartun weight. Am. J. Clin. Nutr. 1980;33:2311-2317.

Luke, B. and P. Rosso. A redefinition of adequate gesta-tional weight change based on postpartumwelght and fetal growth correlations. Am. J. Cl in. Nutr. 1978;31 :713.

Maeder, E. C., Barno, A. and F. Mecklenburg. Obesity: A maternal high risk factor. Obstet. Gynecol. 1975; 45: 669-671.

Naeye, R. L. Weight gain and the outcome of pregnancy. Am. J. Obstet. Gynecol. 1979;135:3-9.

Pipe, N. G. J., Smith, T., Halliday, D., Edmonds, C. J., WI 11 lams, C., and T. M. Col tart. Changes in fat, fat-free mass and body water in human normal pregnancy. Brit. J. Obstet. Gynecol. 1979;86:929-940.

74

Pitkin, R. M. Nutritional Influences During Pregnancy. Med. Cl in. No. Am. 1977;61 :3-15.

Pitkin, R. M. Nutritional support in obstetrics and gynecology. Clin. Obstet. Gynecol. 1976;19:489-515.

Pitkin, R. M. Assessment of Nutritional Status of Mother, Fetus and Newborn. Am. J. Cl In. Nutr. 1981 ;34:658-668.

Prentice, Pa u I. Women.

A. M., Whitehea, R. G., Roberts, S. B. and A. A. Long-term Energy Ba I ance in Chi I dbear i ng Gambian Am. J. Cl in. Nutr. 1981 ;34:2~90-2799.

Seitchik, J., Alper, C., and A. Szutka. Changes in body composition during pregnancy. Ann. N. Y. Acad. Sci. 1963;110:821-829.

Sloan, A. W., Burt, J. J. and C. S. Blyth. Estimation of Body Fat In Young Women. J. Appl. Physiol. 1962;17:967-970.

Taggert, N. R., Hol I iday, R. M., Bi I lewicz, W. Z., Hytten, F. E., and A. M. Thomson. Changes in skinfolds during pregnancy. Brit. J. Nutr. 1967;21 :439-451.

Udall, J. N., Harrison, G. G., Vaucher, Y., Walson, P. 0., and G. Marrow. Interaction of maternal and neonatal obesity. Ped. 1978;62:17-21.

Whitelaw, A.G., Influence of maternal obesity on subcuta-neous fat In the newborn. Br. Med. J. 1976;1 :985-986.

Womersley, J., and J.V.G.A. Durin. A comparison of the sklnfold method with the extent of overweight and various weight-height relationships in the assessment of obesity. Br. J. Nutr. 1977;38:271-284.

75

APPENDIX A

Suggested desirable weights for heights (SDW/H) and ranges for adult females.

Height (cm) 1 Weight (kg)2 80% SDW/H 120% SDW/H

152 49 ( 44-57) 39.2 58.8 158 51 (46-59) 40.8 61 • 2 163 55 (49-63) 44.0 66.0 168 58 (52-66) 46.4 69.6 173 62 (55-70) 49.6 74.4 178 65 (59-74) 52.0 78.0 183 69 (63-79) 55.2 82.8

Adapted from Committee on Dietary Allowances (1980).

1 Without shoes. 2 Without clothes. Average weight ranges In parentheses.

SUBJECT NAME :

DATE:

76

APPENDIX B

PREGNANCY/ANTHROPOMETRIC STUDY

MEDICAL HISTORY

----------------------- SUBJECT It: ----

1. Do you have an illness or condition (other than being pregnant) that requires regular medical care? 1 = yes; 2 = no

A. Allergies B. Specific food allergies C. Asthma D. Respiratory problem ----E. Kidney problem ---,---F. Stomach or gastrointestinal problem ---G. Diabetes ---F. Other, specify ---

2. Do you take any drugs or medications regularly? (1 = yes; 2 = no)

3. If you answered yes to question 2, then specify: 1 = yes; 2 = no

A. Antihistamines B. Aspirin ---c. Aspirin substitutes D • Tr a nq u i 1 i z e i:-s

E. Vitamins and/or minerals F. Other, specify --------------------------

4. Among your brothers, sisters, parents, aunts, uncles, or grandparents is there a known case of: 1 = yes; 2 = no

A. Heart attack B. Stroke ---c. High blood pressure ---D. Hardening of arteries E. High blood cholesterol or triglycerides F. Diabetes G. Cancer

5. How old were you when your menstrual periods started?

Age 1.n years and month (Interviewer calculate and record 10 months)

77

APPENDIX B CONT.

6. Have you ever had menstrual complications (i.e., ammenorrhea)

What --------------------When --------------------Dur at ion ------------------

7. Are your menstrual periods regular? (1 = yes; 2 = no)

8. How long do your periods last? (number of days)

9. How many days lapse between your period?

10. Before becaning pregnant did you take medication for: (l = yes; 2 = no)

A. Pain related to menstruation ---- Specify -------------B. To control regularity or flow of menstruation -----Specify -----------------

11. Have you ever taken birth control pills? (1 = yes; 2 = no) If yes, answer a - C,

months A. How long have you used birth control pills? --------B. Were you taking birth control pills when you became pregnant?

(1 = yes; 2 = no)

C. If the answer to "B" 1.s "no", how long before becoming pregnant had you. stopped taking them?

number of months -------12. How often do you smoke cigarettes?

Record number of cigarettes smoked per day. If never, record "O".

78

APPENDIX C

PREGNANCY/ANTHROPOMETRIC STUDY

SOCIO-DEMOGRAPHIC BACKGROUND INFORMATION

Subject's Name: Subject#:

Date -------1. In which of the following locations do you live?

1. ~1ajor urbnn - > lU0,000 7. Minor urban - > 2500 but < 100,000 3. Rural, non-farm - < 2500 and non-farming 4. Rural, farm - < 2500 and farming

Code subject's residence to the right

2. How many years of scho0ling have vou completed? (Check the highest level of education completed.)

0-5 6-8 9-11

__ completed high school

___ technical or vocational school ___ some college ___ completed college

graduate school

3. Are you employed outside the home? (1 = yes, 2 = no)

4. If employed, do you work: (1 = full-time, 2 - part-time)

5. If employed, what is your occupation?

Note: Refer to Table of Occupations: Levels and Kinds to obtain code for reply to this question.

1 2 3 4

Professional Proprietor Business White Collar

6, What is your marital status?

1 2 3

married widowed divorced

5 6 7 8

4 5

Blue Collar Service Farm Other

separated never married

79

APPENDIX C cont.

7. What is the total number of persons living in your household?

8. \Jho 1 lvC's ! 11 l he ll(lt1~;,·'10 Id wl th you? record the actual number)

(Check the ..ipproprlalt• category and

___ h11sb;111d of sub_jc•ct ___ chi.ldren of subject

f;-ither mother

___ brother (s) ___ sister(s) ___ uncle(s) ___ aunt(s)

___ grandfather(s) ___ male cousin(s) ___ female cousin(s) ___ neice(s) ___ nephew(s)

mother-in-law ==::father-in-law ___ other(s), specify

___ gran<lmother(s) --------

Note: 1·ru111 Lhl' i n[orm;:il ion obtained in question 8, determine the family type us follows:

If family consists of subject and husband, Family Type 1.

If family consists of subject, husband, and children, Family Type 2.

1( familv consists of subject and children, Family Type 3.

J[ [amily consists of subject, husband, and others, Family Type 4.

If family consists of subject only, Family Type 5.

Family Type

9. How many ye:ns of sclwo I ing has your husband completed? (Check the highest level of education co~pleted,)

U-5 6-8

--9-11 ___ completed high school

technical or vocational school ___ some college

completed college ===graduate school

10. Is your husband employed? (1 = yes, 2 no)

11. If employed, is your husband employed (1 = full-time, 2 part-time)?

12, If employed, what is his occupation? (Note: Refer back to Table of Occupations for correct code,)

13. If not employed, is \'our husband

l unemployed 2 retired 3 student 4 homemaker

80

APPENDIX C cont.

Note: For the following questions, please indicate to the subject that the period for reporting income is the past 12 months.

For all sources of income below the following codes are to be used: l = yes, 2 = no.

11,. Wl• m•t•d to reJall• l11r11rmatlon on foo<l habits, 111cal prnetlcctt, an<l health to your sources of income. To keep this completely confidential, I would like you to indicate which of the following ways your household received income last year?

15.

A. B.

c. D. E. F. G. H. I. J. K.

Wages, salary, and/or bonus Social security, veteran's pension (not welfare), or insurance payments Farming Rental Property Welfare Payments Child Support WIC Food stamps <:lfts ([rlcn<ls, relatives) Business Odd jobs or any other source

Now that you have noted the source(s) of your family income, what is the total income (add all sources) before taxes are deducted? You can do this by week, month, or year.

$ _________ weekly $ monthly $ early

•'•*If listed weekly or monthly ask question 1116.

16. How many weeks or months of the year do you make this amount?

weeks -----months -----17. Given the above information in question 15 and 16, what is the subject's total

gross family income?

18. How many people does this income support? (Record actual number)

APPENDIX C cont.

OCCUPATIONAL GROUPS

PROFESS ION AL:

PROPRIETOR:

BUSINESS:

WHITE-COLLAR:

BLUE-COLLAR:

SERVICE:

FARM:

81

Lawyer; judge; physician; engineer; professor; school super-intendent; teacher; librarian; registered nurse; minister; entertainer

Proprietors of large and small businesses

Executive; manager or supervisor of office, department, branch office or bank; buyer and s~lesman of merchandise.

CPA; editors; writer; executive secretary; secretary; steno-grapher; insure or real estate agent; stock broker; bank teller or clerk; ticket agent~ store clerk

Small contractor; foreman; master carpenter; electrician; skilled factory worker

Police; R.R. conductor; barber or cosmotologist; practical nurse; domestic service worker; food, beverage, and lodging worker; amusement and recreation worker; laundr.y, dry clean or furnishing worker; building maintenance worker, janitor

Farmer or landowner; farm and land supervisor or operator; operator of leased property; tenant on farm; migrant worker; forestry worker; share cropper

Subject's Name:

Date

82

APPENDIX D

PREGNANCY/ANTHROPOMETRIC STUDY

FOOD AND HEAL TH HABITS

Subject #:

1, How many times per week do you usually take nutritional supplements such as vitamins, minerals, or protein in addition to the foods you eat?

Circle one: 0 1 2 3 4 5 6 7

2. If you take supplements, who recommended that you take the supplements? (select one)

1. Physician 2. Self 3. Media 4. Friend(s) 5. Husband

3. What supplements did you take yesterday? How many capsules or tablets, and at what time were they taken?

Supplement Name

Concentration of Tablet Frequency

4-, When you eat/drink snacks do you eat or drink them:

1 = Never; 2 = Sometimes; 3 = Often

a. Because you are hungry? b. To be social or part of a social activity? c, Just to have something to do? d, Because you see something that looks good? e, To ~ain weight? f. 0 tlwr reason

Time

83

APPENDIX D cont.

5. Are you presently on a vegetarian diet? yes= l; no= 2

6. As a vegetarian do you eat: yes= l; no= 2

a. eggs b. milk c. cheese d. fish

7. Are you a vegetarian for (circle one)

1. religious reasons. 2. humanitarian reasons. 3. dislike. 4. economic reasons. 5. health reasons. 6. lifestyle.

8. How long have you been a vegetarian?

9. Have you ever been on a weight reduction diet? If answer is No skip to question #14.

(specify in months)

_____ yes= l; no= 2

10. If yes, was it recommended or decided on pr~_marily by: (select one)

1. Physician 2. Family members (other than husband) 3. Self 4. Friend(s) 5. Husband 6. Media

11. Have you been on a weight reduction diet within the past year? yes= l; no= 2

12. How many times each year do you go on a weight reduction diet?

13. How long does the diet usually last? (select one)

1. less than one month 2. 1-3 months 3. 4-6 months 4. more than 6 months.

14. Have you ever been on a diet to try to gain weight? yes= l; no= 2

15. Have you tried to gain weight within the past year? ___ yes= l; no= 2 If answer is No skip to question #17.

84

APPENDIX D cont.

16. If yes, was it recommended or decided on primarily by (select one):

1. Phys i.ci an 2. Faml ly ml'mlwn; (othl'r thnn husbnnd) J. Sl'I f 4. Friend(s) 5. Husband 6. Media

17. Are you presently trying to ___ weight? gain= l; lose= 2; neither= 3

18. Are you dieting to lose weight? ----- yes = 1; no = 2

19. How much weight do you want to gain or lose (pounds)?

20. Do you think your weight is now:

Circle one: 1 = too heavy 2 = too light 3 = about right

21. Do you add salt to your food at the table?

1. almost never 2. sometimes 3. almost always but only after tasting 4. almost always and before tasting

22. Do you like very salty foods such as salted nuts, potato chips? __ _ yes = 1; no = 2

23. Who does most of the grocery shopping in your family? (select one)

1. You 2. Your husband 3. You and your husband together 4. Whole family (if different than answer #3) 5. Other: specify ________________________ _

24. Who makes the majority of decisions about the groceries to buy?

1. You 2. Your husband 3. You and your husband together 4. Whole family (if different than answer #3) S. Other: specify ________________________ _

85

APPENDIX E

PREGNANCY/ANTHROPOMETRIC STUDY

EXERCISE AND ACTIVITY LEVEL QUESTIONNAIRE

Below is a list of exercises and activities. Each question has 3 parts. If you participate in the activity or exercise on a weekly basis, please canplete all 3 parts. If you do not participate in the activity, please leave blank.

Terms Defined: Light--no sweating; Mild--limited sweating; Moderate--sweating within 5 minutes; Vigorous--profuse sweating

1. Baseball and/or softball A. Days/week 1 2 3 4 5 6 daily B. What level o77"ntensity-:-lig~ mTTd--moderat_e_ vigorous C. How long?______ -- -- -- --

2. Basketball A. Days/week 1 2 3 4 5 6 daily B. What level orfnterisfty:1ight mTTd moderate vigorous_ C. How 1 ong? -------

3. Bowling A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:light mild moderate vigorous_ C. How 1 ong? -------

4. Calisthenics A. Days/week 1 2 3 4 5 6 daily B. What level o17""ntensity-:-light mild moderate vigorous_ C. How 1 ong ? ______ _

5. Canoeing A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:light mild moderate vigorous_ C. How long? -------

6. Dancing (square, clogging, ballroan, modern) A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:lig~ mTfd --moderat_e_ vigorous C. How long?_______ · -- -- -- --

86

APPENDIX E cont.

7. Chopping wood A. Days/week 1 2 3 4 5 6 daily B. What level oflntensity:light mild moderate vigorous_ C. How long? -------

8. Gardening A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:light mild moderate vigorous_ C. How long? -------

9. Golfing A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:light mTTd moderate vigorous_ C. How long? -------

10. Racquetball A. Days/week 1 2 3 4 5 6 daily B. What level oflnterisTty_:_lig~ mTTd --moderat_e_ vigorous C. How long?_______ -- -- -- -

11. Cross Country Skiing A. Days/week 1 2 3 4 5 6 daily B. What level of intensity-:-lig~ mTTd--moderat_e_ vigorous C. How long?_______ -- -- -- -

12. Downh il l Ski i ng A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:lig~ mTTd --moderat_e_ vigorous C. How long?_______ -- -- -- -

13. Soccer A. Days/week 1 2 3 4 5 6 daily B. What level oflntensity:light mild moderate vigorous_ C. How long? -------

14. Sprinting A. Days/week 1 2 3 4 5 6 daily B. What level of intensity-:-light_ mild moderate vigorous_ C. How long? -------

15. Rugby A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:light mild moderate vigorous_ C. How long? -------

16. Tennis A. Days/week 1 2 3 4 5 6 daily B. What l eve 1 orl"ntens ity:li ght rmTd moderate vigorous_ C. How long? -------

87

APPENDIX E cont.

17. Vol leybal 1 A. Days/week 1 2 3 4 5 6 daily B. What level of intensity:lig~ mTTd --moderat_e_ vigorous C. How long?_______ -- -- -- -

18. Weight lifting A. Days/week 1 2 3 4 5 6 daily B. What level ofTntensity:lig~ mTTd --moderat_e_ vigorous C. How long?_______ -- -- -

19. Recreational biking A. Days/week 1 2 3 4 5 6 daily B. What level ofTntens ity-: -1 ig~ riiTfd --moderat_e_ vigorous C. How long?______ -- -- -- -

20. Other A. D·_a_y_s /..,...w_e_e..,...k--r-l--=2---,,,3--.... 4----=5,_ 6 da; l y B. What level of intensity:light mild moderate vigorous_ C. How long? -------

Part II: Please answer the following questions.

1. What is your main form of transportation?

Car Bik_e ___ _

Walk ----Other Explain --- -------------------What is the distance you walk/bike per day?

less than 1 mile 1-2 miles ----2-3 miles greater t~h_a_n~3----m~i~l-es--

2. Do you hike? no __ yes __

If yes, how many times per month ----On the average, what is the di stance covered? ----

APPENDIX E cont.

3.

4.

Do you Types:

Do you Types:

run? no yes Cross Country --

days/week_-_-_-_-_ miles/run ---how 1 ong

Field House _o_r_T-r-ack days/week mi 1 es/run __ _ how long

Graded Surfa_c_e __ days/week ---miles/run ---how long ---

swim? no yes __ Recreational ---days/week ---#laps/swim

how 1 ong ---Team swim ----days/week ---#laps/swim ---how 1 ong

88

Part III: Please answer the following questions.

1. Do you plan to change your exercise/activity level(s) due to being pregnant?

yes no unsure

2. If the answer to question #1 was "yes," please explain what changes you anticipate making:

89

APPENDIX F

PREGNANCY/ANTHROPOMETRIC STUDY

FOOD KNOWLEDGE AND BELIEFS

1. The diet of a woman before and during pregnancy can affect how healthy her baby will be.

2. Snacks can be an important part of your nutrient intake.

3. A pregnant woman needs to increase her intake of certain vitanins, minerals, and calories.

4. The way a food is prepared can change the amount of nutrients contributed to the di et.

5. Anemia can be prevented by eating foods high in calcium.

6. The "Basic Four" refers to the four things to do if your child is sick.

7. A fat baby is a healthy baby.

8. A fat child is at risk of becoming a fat adult more so than a slim child.

9. When a baby cries it is usually hungry.

10. Solid foods should be introduced as early as possible to an infant.

11. Cow's milk should not be given to an inf ant before 4 months of age.

12. Commercially prepared baby foods contain added salt and sugar.

Agree Disagree Don I t Know

90

APPENDIX G

PREGNANCY/ANTHROPOMETRIC STUDY

HOME INTERVIEW INFORMATION

SUBJECT'S NAME: SUBJECT#: ------------- ------INTERVIEW APPOINTMENT: DAY DATE TIME ----- ----- -----AGE: ------------ADDRESS: --------------------------PHONE : (home) ------- (work) -------PLACE OF EMPLOYMENT: ---------------------HUSBAND Is NAME: DOCTOR'S NAME: ---------IS THIS YOUR FIRST PREGNANCY? YES NO

IF NO - HOW MANY OTHER CHILDREN DO YOU HAVE? ----WHAT ARE THEIR AGES? -------

WAS THIS PREGNANCY PLANNED? YES NO

WHAT IS YOUR DUE DATE? --------DO YOU PLAN TO BREAST-FEED OR BOTTLE FEED? ------------COM fvE NTS:

NOTES FOLLOWING INTERVIEW:

TOTAL LENGTH OF TIME TAKEN FOR INTERVIEW: --------DATE SIGNATURE OF INTERVIEWER

91

APPENDIX H

72-HOUR FOOD RECORD

SUBJECT NUMBER ------DATE ----------

FOOD ITEM AMOUNT EATEN HOW PREPARED

I,

APPENDIX I

PREG ?

THE DEPARTMENT OF HUMAN NUTRITION AND FOODS AT VIRGINIA TECH IS PLAN-~ING A STUDY USING HEALTHY PREGNANT WOMEN,

SEVERAL BODY MEASUREMENTS WILL BE TAKE FROM THE l~TH WEEK OF PREGNANCY UNTIL SIX MONTHS FOLLOWING DELIVERY,

MONETARY COMPENSATION WILL BE GIVEN FOR PARTICIPATION,

IF YOU ARE INTERESTED IN PARTICIPATING, PLEASE PHONE 961 5987 FROM 9 AM TO 1 PM AND ASK FOR DIANE DOWNING OR MARY DELATORRE,

92

93

APPENDIX J

PREGNANCY/ANTHROPOMETRIC STUDY

WRITTEN EXPLANATION OF STUDY FOR POTENTIAL PARTICIPANTS

If you are pregnant your doctor has probably talked to you about weight gain during pregnancy. Current research has raised the question about what is "optimal" weight gain during pregnancy and whether this "optimal" or "normal" weight gain might be influenced by the woman's pre-pregnant body weight and body build. Some researchers have shown that underweight women entering pregnancy need to gain more than the recommended amount of 24-28 lbs. while the overweight woman entering pregnancy may not need to gain as much. The woman's body builds up fat stores during the first half of pregnancy and some women mobilize this extra fat during the second half of pregnancy to support the rapid growth of the baby during this time. Measures of skinfold thickness, as well as height and weight, have been widely used in an attempt to assess body fat changes during pregnancy.

The purposes of this study are to: 1) assess changes in skinfold measure-ments and weigl1t throughout pregnancy and for a six month period following deliv-ery; 2) in retrospect, relate changes in skinfold fat to weight gain during ges-tation and weight loss following delivery; 3) relate changes in skinfold thickness and weight to dietary intake information collected throughout the period via 24 hour recalls; and 4) plot urinary pH, glucose, protein, and ketone excretion over the course of pregnancy and relate this to food intake and skinfold thickness changes.

Much research needs to be done to help the medical community do everything possible to insure the mother's and baby's health both during and following preg-nancy. Your participation may help to provide a .missing link. If you have any questions or concerns please let us know.

94

APPENDIX K

PREGNANCY/ANTHROPOMETRIC STUDY

CONSENT OF PARTICIPATION FORM

Optimal maternal weight gain during pregnancy appears to be a very individualized phenomenon. The majority of weight gained in a normal pregnancy is the result of physiological changes that are designed to foster fetal and maternal growth. Much of the weight gain can be accounted for by the products of gestation. Research has shown that maternal weight prior to pregnancy may have an effect on maternal weight gain during pregnancy. Most of the weight gain attributable to the developing fetus occurs during the second half of pregnancy, when the fetus is growing at a very rapid rate, However, the maternal stores increase in quantity most rapidly before the middle of pregnancy and seem to stop enlarging before term. Measures of skin-fold thickness, as well as height-for-weight, have been widely used in an attempt to assess body fat changes during pregnancy.

The purposes of this study are to:

(1) assess changes in skinfold measurements and body weight throughout pregnancy and for a 6 month period following delivery,

(2) in retrospect, relate changes in skinfold fat to weight gain during gestation and weight loss following delivery,

(3) relate changes in skinfold thickness and weight to dietary intake information collectP.d throughout the period via 72 hour food recalls, and

(4) plot urinary pH, glucose, protein, and ketone excretion over the course of pregnancy and relate this to food intake and skinfold thickness changes.

I have received an explanation of the Nutrition Study to be conducted at Virginia Tech in the Department of Human Nutrition and Foods, The project will be directed by Dr. Janette Taper, faculty member, in the Department of Human Nutrition and Foods.

I understand that I will be asked to answer questions about socioeconomic back-ground (education, occupation, etc,), food habits, over-all health, and lifestyle (exercise, etc.). I understand that I will be asked to come to the Virginia Tech campus for skinfold thickness and weight measurements during weeks 12, 16, 20, 24, 28, 32, 36, 40 of gestation and at monthly intervals for the first six months following delivery. I will also be asked to give a urine sample for measurements of urinary glucose, protein, pit, and ketones each time that I come in.

TI1e potential risks of this study (such as stress during the interview and tests) have been explained to me. I understand that I will receive $ _____ for being a subject in the study, payable at the end of my participation.

95

APPENDIX K cont. I understand that I am free to withdraw from the study at any time. I under-

stand that all information will be considered private, will be treated in a confi-dential manner, and will not be revealed sn as to cause embarassment. Dr, Taper or one of the other members of the research staff will be free to answer any questions I may have regarding this study.

U11dl•rsta11<l lng the ahovc, l agree to participate in the Nutrition Study to be conducted at Vir~inia Tech.

Signature of Subject

Social Security Number

Date Signature of Interviewer

Principal Investigator: Dr. L. J. Taper (961-5549)

96

APPENDIX L

PREGNANCY/ANTHROPOMETRIC STUDY

FOOD RECALL

Subject's Name: Subject #: ------------- -------Date ------

Instructions for Completing a 3/day Food Record

Included is a food record chart. The infonnation you provide in the following pages will be used to help tell us the canposition of your diet. With these values, your weight gain and body measurements, we will attempt to assess which nutrient reserves supply deficient nutrients and store excess nutrients.

It is important that you be as specific and accurate as possible in recording your food intake. Instructions for recording your meals are as fol lows: (Please refer to the attached example chart.)

1. List the time of day you eat a snack or meal.

2. Next list the items of food you ate. Please break each food into the canpenents_ it is made of: eggs, skim milk, salt, pepper, etc.

3. List how much of each you ate: 2 eggs, 3 tablespoons of milk, dash of sa 1t and pepper.

4. List how much was prepared: eggs scrilllbled and fried in two tablespoons of margarine. Be sure to include any foods used in preparation.

5. If you ate a fast food, list where you ate next to the item (Wendy's, McDonald I s}.

Below are some questions to help you complete the fonn without forgetting any foods or making an error in serving size. It may help you to tape the record sheet to your refrigerator door so you may fill out the chart as you prepare your meals and snacks.

1. Do you usually eat or drink something before your morning meal? If so, 1 i st this.

2. Do you snack throughout the day? If so, 1 i st al 1 snacks.

97

APPENDIX L cont.

3. Do you periodically purchase snacks frun vending machines? Include these: gum, candy, etc.

4. Remember to list condiments like ketsup, mustard, relish. These are important food sources.

5. Define the type of foods you eat; if you drink milk, is it skim, 2%, whole 1 chocolate?

6. If possible list foods like sandwiches and casseroles separately; hclll and cheese sandwich--2 pieces of whole wheat bread, 1 tablespoon mayonnaise, 1 leaf lettuce, a 4 oz. slice of ham, 2 oz. swiss cheese.

7. You can't be too specific! List anything that you think will help us--the type of juice (orange or apple). If you have any questions, don't hesitate to call!

APPENDIX L cont.

Time of Day

8:00 a.m.

9:15 a.m.

11:30 a.m.

SAMPLE FOOD RECORD

Food Iten and Contents

Skim milk Orange juice Eggs, scranb led with

3 T skim milk, fried with 2T margarine

Salt and pepper to taste

Toast - plain

Yogurt, lowfat strawberry Banana Rye crisp crackers Iced Tea - brewed

with sugar

Amount Eaten

1 cup 6 oz. 2 3 r" 2 T dash

1 piece

1 cup 1 4 8 oz. 1 teaspoon

How was this prepared

'° co

90

80

If

8 70

,.,

r

60

-

...

J4 28

WEEKS Op GESTATION

,:---+

-+ 10

10

-*--It

36 40

APPENDIX M2 ESTDIATED REGRESSION EQUATIONS WITH 95X CONFIDENCE INTERVALS

• NORMAL WEIGHT TRICEPS SKINFOLD THICKNESS {Wl) + OVERlfEIGHT

28

271_ - - - - - - - - - - - - - - - - - -26* + + +

25-I + + T 24~- - - - - - - - - - - -- - - - - ...... - - ___... 0

0

R I 23 C E 22 p S 21

20J_ - - - -19-I

- - -- -- -*

-,c - - - - - - - -*

18-F * - - - - - - - -17~- - - - - - _ * * ,......... - -, ......... ,.. - -12 ,,,,,, ••• 16 ' 1 '''''''''1' 20 I I I I I I 24 • I I I I I I I I I I I I I £-8 32 I I I I I I I I I

WEEKS OF GESTATION 36 40

APPENDIX M3

ESTDU.TED REGRESSION EQUAnONS WITH 95" CONFIDENCE INTERVALS• NORMAL WEIGHT SUBSCAPULAR SKINFOLD THICKNESS (MK)+ OVERWEIGHT

:1 -- ---- - - - - -

22 +

+

---

+

+

--

s -

U 21 -

- --- --- - - -- -+-

B

S 20� C

A 19

p

U 18

L

A 17

R

16

- - -

15

14

13

12 16

- - - --

*

-

20

-

*

---------

24

28

WEEKS OF GESTATION

32 36 40

,_. 0 ,_.

• HORII.AL WEIGHT + CJvERWEIGHT

2~ . 23-f

22-I - -21-f

20l D 19 A - -X 18 I L 17 L A 16

15~

APPENDIX M4 ES'l'DUTED REGRESSION EQUATIONS 'WITH 95" CONFIDENCE IN11:RVALS

KIJlADirlJRY SiaNl'OLD THICKNESS (MM)

--- - - - - - - - - - - -+

+ + + +

- - - - - - - - - - --- -

-- - -

---,;I-

- - -

---14-I - -13-i

- - -*

- - -*

- -12-I

- * * 11-1- - - - - - - - - - - - _ * * "ii<

I'""' - - -I I i

12 1•••••••

I i I 16 I I I I I • I I • 20 I I I I I I I I I I I 24 I • 1 • , ,

I I i 28 I I I I I I I I

WEEK "' S OF GESTATIO 32 I • ' ' o I I ' ' N 36 1 I 40

0 N

•HORIIALHIGBT + OVERWEIGHT

30

A 20 B D 0 M I N A L

10

-- --- --- -

APPENDIX MS ISTDU.TED REGRESSION EQUATIONS 1'lTH 95~ CONFIDENCE INTERVALS

ABDOIIIHAL SKINJ'OLD THICKh"'ESS (IOI)

..__+ __ -- .._.. -- --- - --- --.._ - --.._ - - ' - - -...........

' ...........

o, a,,r-,,r-,r-,,r-,ar-,1-,1-r,-,1-,l""'Tl""'Tl ""'Tl ""'Tl ""'Tl --,,r-,,r-,,.-,,r-i,r-iar-,,-,,""'T,""'Tl""'Tl""'Ti ""'Ti-,-,-,-,-,-, --iar-,,,-,,,---,,r-,,,---,,,---,,.-,,,-,lr-"llr-"llr-"ll,-,ir-,,-.,-.,...,. •. -1--r,-Tj .....-i -ra -r, -,.-,,.-,,,.--,,..-,1.--,,.-,j,-,,,....,,,-,,,....,,,-,,,-,i~-.,--.,--.,-, 12 16 20 24 28 32 36 40

WEEKS OF GESTATION

-0 w

• NORMAL WEIGHT + OVERWEIGHT

40.00

38.11

36.22

S 34.33 u p R 32.44 A I L 30.56 I A C 28.67

26.78

24.89

_...

/

_...

/ /

APPENDIX M6 ESTDUTED REGRESSION EQUATIONS WITH 95X CONFIDENCE INTERVALS

SUPRAUJAC SKINFOLD THICKNESS {IDl)

- - --- --- + _... + _... _...

+ - - -----/ /

/ /

_......- - - ---

- -'-...

'

- -_... --_... - - - -- ---_... -----/ ' / ' /

/

-+ ...

-*

....

23.00 I .,, ..... ,...,.,-,r-i, ....... ,-.-• ..,, ..... ,...,., ......... ,...,...,,.-,, ..... ,-r, ... , ....... ,-.-. ,, ........ -.-..,, ....... ,...,., ..,, ..... ,...,., ...... , ... , ...... ,-.-• ..,,.....,,...,.,-.-, ..,, ..... , ..... ,-,....,,...,.,-.-..,, ...... ,...,.,-,.-., ..... ,-, ... , ..... ,...,.,_,,...,,...,.,-, .,, ..... ,""T.-, ..... ,,......,-.-, .,, ..... ,...,., .,, ....... ~. 12 16 20 24 28 32 36 40

WEEKS OF GESTATION

...... 0 .i:,.

• NORMAL WEIGHT + OVERWEIGHT

37,- -

T

36

35

34

33

H 32 I 6 3i H

30

29

28

27

-

-

APPENDIX M7 ESTDCA.TED REGRESSION EQUATIONS WITH 95" CONFIDENCE INTERVALS

THIGH SKINFOID THICKNESS (llll)

- - - - - - -------+------

+ + + +

- - - - - - - - -- - -

-- - - - - - - -• * *

* * - - -- - - - - - -

- -+

- -

- -

-*

26 ,. I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I i I I I I I I I I I I 1

12 16 20 24 28 32 36 40 WEEKS OF GESTATION

...... 0 U1

APPENDIX M8 ESTIMATED REGRESSION EQUATIONS Wiffl 95,C CONFIDENCE INTERVALS

• NORMAL WEIGHT KNEE SKINFOLD THICKNESS {IOI} + OVERWEIGHT

29

28 - - - - - ..±.. 27 + 26

2e

24 + K 1- - -N 23 E

-* - - --E 22 -- -- --21~ - - - -- - - --.,,,.. - --20~ .,,,.. -- --.,,,.. .......... 19 ..........

18

17

16 I • • I I I I I ' I I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I i I I I I I I I I 12 16 20 24 28 32

WEEKS OF GESTATION

+

- -..........

' 36

+

-

' ' 40

'""' 0 °'

27

- ... ---

-

-

25

=2 -== --

23 - - -

--

-- - ---

C 2i�

--/

\..

f i9

i1

i5

-

r -

--

--

--

--

_ ...

- -

=

- -

-

,.... 0 ..J

105

103

101

99

97 -95

93

91

89

87 -

85

12

---- ,+

lt._-

-r:-

---=-=�-===*--=::-::--=-

---- --

*

16

� 28 � WEEKS OF GESTATION

....

0 a,

• NORMAL WEIGHT + OVERWEIGHT

N A I s T

uo

100 ..

90

BO

70~--r,, 12

APPENDIX :Ml 1 ESTllUTED REGRESSION EQUATIONS WITH 95" CONFIDENCE INTERVALS

WAIST CIRCUMFERENCE (CM)

--- --- ___ __::::::..-::, r-::

I I I I I I I I I I I 16 20 24 28 32 36 40

WEEKS OF GESTATION

,.... 0

"'

• NORMAL WEIGHT + OVERWEIGHT

108 I

106-I

104-I

102-1- -H 100r--I p --s 98

96'

94

92

90

APPENDIX :Ml2 ESTIMATED REGRESSION EQUATIONS '11TH 95% CONFIDENCE INTERVALS

HIP CIRCUMFERENCE (CM)

------------- - - - - - -+

+ - - - - - - --------------- - - - --- --* - - --- -

-------- -

-- -- -

I I I I I • I I I i i i I ' I I I I I I I I • I I i ' I ' ' I I I I I I I I I I I I I I I I I I I I I I I I I I 36 I I I I 12 16 20 24

WEEKS OF 28 GESTATION 32 40

......

...... 0

• GHT+

NORMAL WEI OVERWEIG

HT

62

61

60

59

T 58

H

I 57

H 56 /

55

- --

54

53 -

-

52

12 16

APPENDIX Hl3

.EB'rDu.TED REGREBsioTHI

N Gl!:H Q

CUA

IRnCONS WITH

115%

UJiFERENCE ( CCM)O

NFIDENCE INTERvALS

- - -- - - -

-

-

-

-

-

-

�

--

-

+--

--

.........

.........

-

-

-

- -

-

* *

*

- -- -

-

--

20 24 28 32 36 40

WEEKS OF GESTATION

,_.,_. ,_.

•!S'rnu.TED REGREsmo11

C4IJP .!QU4

AP

'17P

0EN

�.NS DIX l-1

1flTH 14

96%

CE ( CM)

COHFmQcg INTERv.u.,

+NOOVEliiRll4I.

rEIG'l'EIG.IIT

HT

39

38

-

--

-

37

...

...

...

-

_ ... _

-

+ -

-

A 36

35

-

-

-

-

-

--

* *

•

* •

*

--

-

-

-

-

-

-

33

12 16 20 24 28 32 36

WEEKS OF GESTATION

--

-

.....

.....

-

*

--

40

• NORMAL RIGHT + OVERWEIGHT

23.00

22.75

22.50

22.25

22.00

APPENDIX Ml5 ESTDU.TED REGRESSION EQUATIONS WITH 95" CONFIDENCE Ui11!RVAUi

ANKLE CIRCUMFERENCE (CK)

-:.:---,:--+ + --,----

A 21.75 N K 21.50 L E 21.2!5

21.00

20.7!5

,_ 20.!50,-

20.25

20.00 ,.,. 12

--

* * *

i I I I I I I I I i I I I I I I I I I i I I 16 20 24 28 32 36 40

WEEKS OF GESTATION

..... ..... w

• NORMAL WEIGHT + OVERWEIGHT

30

29

U 28 p p E R 27

A R M 26

APPENDIX Ml6 ES'l'IllATED REGRESSION EQUATIONS 1fITH 95,; CONFIDENCE INTERVALS

UPPER ARM CIRCUMFERENCE (CM)

-+ +

- - --t-

~- - - - - - - - - - - -· * a4 --------! - - -

r, i I illilliiflliili' llilliif 24 . . " " ,. o, I " " " J " • " I 36 40

.-, ,,,.,,,, 12 16 20 24 28 32

WEEKS OF GESTATION

,_. ,_. .i:,,.

APPENDIX Ml 7 ESTDUTED REGRESSION EQUATIONS WITH 95~ CONFIDENCE INTERVALS

• NORMAL HIGHT WRIST CIRCUMFERENCE (CM) + OVERWEIGHT

17.00

16.75

16.50

16.25~ - - - - - -16.00-i

+- - - - -- - - - - - -+ .... ..... u,

" 15. 751 + -+-

A L- - - - - - - - - - -- - - - -I 15.!50 s T 15.25; - -15.00-i * - - - - - -- - - - - - - -

* * * * * * 14.75,- - - - - - - - - - - -- - - - -1<4 .!50

14.25

14.00 I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I i I i I I I I I i I I I I I I I I 12 16 20 24 28 32 36 40

WEEKS OF GESTATION

• NORMAL WEIGHI' + OVERWEIGHT

1700 I

1600-I

1500~

I B 1400 0 D Y 1300

F ~- -1200

uoo I ,,,,.,.,, /

100.0 -I

900

12

APPENDIX Ml8 ESTDUTED REGRESSION EQUATIONS WITH 95" CONFIDENCE INTERVALS

BODY FAT (Mil)

+ -- +-+

+ _+_ -- -- - - - - - - - -- --

- - - - -- - -- - -- - - - - - -

+ -- - -- ___....

........... ...

I I I ' I I I I ••r• I I 1 I I 1 i I I I I i I I I I ' I I ' I I I I I I I I I I I I I I I I I ' I I I 16 20 24 28 32 36 40

WEEKS OF GESTATION

...... ...... °'

• NORMAL WEIGHT + OVERWEIGHT

50.0

p E

i 400i- --N T

B 0 D y

F 30Dl A - -T

/"' .,,,,,-20.0

12

APPENDIX Ml 9

ESTIMATED REGRESSION EQUATIONS WITH 95~ CONFIDENCE INTERVALS PERCENT BODY FAT

-+- - -+

-- -- -- - -- -- -- - ~- -- -- - - -+

--- * - -- * - - - -- -- -- -- -

--+

- --

* --.. --I I ' I I • ' ' I I ' ' I I I I ' I I ' I I I I ' I I I I I ' I I I I I I I j '

lf 20 24 28 32 36 WEEKS OF GESTATION

+ -- ...... ...... -.J

--I I I

40

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