Effects of prenatal exercise interventions on maternal body composition: A secondary analysis of the FitMum randomized controlled trial

Caroline Borup Roland; Parisa Seyedhosseini; Signe de Place Knudsen; Anne Dsane Jessen; Ida Karoline Bach Jensen; Jane M. Bendix; Gerrit van Hall; Stig Molsted; Saud Abdulaziz Alomairah; Ellen Løkkegaard; Bente Stallknecht; Tine D. Clausen

doi:10.1371/journal.pone.0308214

Abstract

The main objective of the study was to investigate the effects of prenatal exercise interventions on maternal body composition at 28 weeks gestation and 7–14 days after delivery. We also explored associations between physical activity (PA) per se and body composition. This study presents secondary outcomes of the FitMum randomized controlled trial, which included healthy inactive pregnant women at gestational age ≤ 15+0 weeks. They were randomized to structured supervised exercise training, motivational counselling on PA, or standard care. Maternal body composition was measured by doubly labeled water at 28 weeks gestation (n = 134) and by dual-energy X-ray absorptiometry scan 7–14 days after delivery (n = 117). PA, including moderate-to-vigorous-intensity PA (MVPA), active kilocalories, and steps, were measured continuously from inclusion to delivery by a wrist-worn activity tracker. One hundred fifty pregnant women were included with a median pre-pregnancy body mass index (BMI) of 24.1 (21.6–27.9) kg/m². We found no differences between groups in fat mass, fat percentage or fat-free mass at 28 weeks gestation or 7–14 days after delivery. Visceral adipose tissue mass and bone mineral density measured 7–14 days after delivery did not differ between groups either. Linear regression analyses adjusted for pre-pregnancy BMI showed that a higher number of daily steps was associated with lower fat mass, fat percentage, and visceral adipose tissue mass at 28 weeks gestation and 7–14 days after delivery. Active kilocalories during pregnancy was positively associated with fat-free mass 7–14 days after delivery. Neither structured supervised exercise training nor motivational counselling on PA during pregnancy affected maternal body composition at 28 weeks gestation or 7–14 days after delivery compared to standard care. Interestingly, when adjusted for pre-pregnancy BMI, higher number of daily steps was associated with lower fat content during pregnancy and after delivery, whereas MVPA and active kilocalories were not.

Trial registration: ClinicalTrials.gov; NCT03679130; 20/09/2018.

Citation: Roland CB, Seyedhosseini P, Knudsen SdP, Jessen AD, Jensen IKB, Bendix JM, et al. (2024) Effects of prenatal exercise interventions on maternal body composition: A secondary analysis of the FitMum randomized controlled trial. PLoS ONE 19(8): e0308214. https://doi.org/10.1371/journal.pone.0308214

Editor: Everson Nunes, McMaster University, CANADA

Received: February 1, 2024; Accepted: July 18, 2024; Published: August 1, 2024

Copyright: © 2024 Roland et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request. We can transfer individual participant data when we have obtained approval from the Danish Data Protection Authority according to the Data Protection Act and completed a SCC (Standard Contractual Clause) to ensure the legal basis of the transfer. The data restriction is set out by the Danish Supervisory Authority (Datatilsynet). In a case regarding publication of raw data in a journal Datatilsynet has proclaimed such a wide, unrestricted publication to be in violation of Danish law. This is due to Danish law restricting the transfer of data via the Danish Data Protection Act, art. 10(3)(3). Data requests may be send to section of Research Law (Forskningsjura), Copenhagen University Hospital - Rigshospitalet (forskningsjura.rigshospitalet@regionh.dk). Please make sure to always direct data access requests to Caroline Borup Roland (carolineborup@hotmail.dk) and Tine Clausen (tine.clausen@regionh.dk) as well.

Funding: The Independent Research Fund Denmark (8020-00353B), received by B.S. https://dff.dk/en TrygFonden (128509), received by B.S. https://www.tryghed.dk/ Beckett-Fonden (17-2-0883), received by B.S. https://beckett-fonden.dk/ Aase and Ejnar Danielsens Fond (10-002052), received by B.S. https://danielsensfond.dk/ Familien Hede Nielsens Fond (2017-1142), received by B.S. https://www.hedenielsensfond.dk/ Copenhagen Center for Health Technology (061017), received by B.S. https://www.cachet.dk/ Financial support was also provided by the University of Copenhagen and Copenhagen University Hospital – North Zealand, Hilleroed. The grants awarded by the Independent Research Fund Denmark and TrygFonden included external peer review for scientific quality. None of the external funding bodies interfered with the design of the study and collection, analysis, and interpretation of data, and eventual reporting of the study.

Competing interests: The authors have declared that no competing interests exist.

List of abbreviations: BMI, Body mass index; CON, Standard care; DLW, Doubly labeled water; DXA, Dual-energy X-ray absorptiometry; EXE, Structured supervised exercise training; GWG, Gestational weight gain; MOT, Motivational counselling on physical activity; MVPA, Moderate-to-vigorous-intensity physical activity; PA, Physical activity

Introduction

Maternal obesity and excessive gestational weight gain (GWG) pose global challenges, increasing the risk of adverse pregnancy outcomes and long-term obesity and cardiometabolic diseases for both mother and child [1–3]. Measuring maternal body weight, body mass index (BMI) and GWG reflect the total changes in several maternal and fetal components such as fat mass, fat-free mass, total body water and placenta, but total body weight measurements do not reveal the precise contribution of each component [4]. While fat mass is expected to increase to some extend during pregnancy [4–6] due to expansion of subcutaneous fat etc., excessive fat mass seems to be associated with impaired maternal cardiometabolic health during pregnancy [6–9]. Previous studies have shown that fat mass, fat mass index (fat mass divided by height squared) and fat percentage are strongly associated with insulin resistance during pregnancy [6–9], gestational diabetes mellitus, and other markers of cardiovascular disease [7]. Maternal body composition during all trimesters of pregnancy has also been associated with short-term infant health outcomes including birth weight [10–13], early postpartum infant fat mass [14, 15], and fat-free mass [15]. Moreover, two small observational studies have indicated that postpartum maternal BMI and body composition may be associated with breast milk composition and might hereby play a role in childhood obesity [16, 17]. Thus, understanding changes in maternal body composition during pregnancy and postpartum in the absence of clinically significant change in GWG may be of interest.

Prenatal physical activity (PA) measured by different methods has been indicated by some studies to be associated with changes in maternal body composition measures [18–20]. However, only few randomized controlled trials have been conducted in this field and these were either targeted overweight women or used inferior methods to measure body composition [21, 22]. An accurate assessment of maternal body composition seems important to gain a more detailed understanding of how changes in volume and distribution of different tissues relate to maternal and infant metabolic health. Advanced methods can be used for assessing body composition during pregnancy, such as the doubly labeled water (DLW) technique, but major limitations include the inability to distinguish between maternal and fetal tissues, as well as regional distribution [23–25]. Dual-energy X-ray absorptiometry (DXA) is the most widely used method to measure body composition in women who are not pregnant and men. DXA shows similar accuracy as magnetic resonance imaging, which (together with computed tomography) is considered the gold standard for measurement of body composition [26]. The use of DXA scans are not recommended during pregnancy due to ionizing radiation exposure [25], but DXA measurements of body composition just before and/or after pregnancy have been suggested to be meaningful for obtaining insights into maternal body composition during pregnancy [23].

The aim of the present randomized controlled study was to investigate the effects of prenatal exercise interventions on maternal body composition measured by DLW at 28 weeks gestation and by DXA scans 7–14 days after delivery. Additionally, we explored the associations between measures of PA per se (from randomization to 28+6 weeks gestation and to delivery, respectively) and various measures of body composition at 28 weeks gestation as well as 7–14 days after delivery.

Materials and methods

Participants and study design

The FitMum study was a randomized controlled trial conducted in 2018–2021 at the Department of Gynecology and Obstetrics at Copenhagen University Hospital–North Zealand, Hilleroed, Denmark (recruitment from October 1^st 2018 to October 15^th 2020). Healthy (no pre-existing or ongoing obstetric or medical complications), inactive (structured exercise at moderate-to-vigorous intensity < 1 hour/week during early pregnancy) women with gestational age ≤ 15+0 weeks were eligible for inclusion. This paper reports secondary outcomes of the study and includes participants with available data from DLW analysis (n = 134) and/or DXA scan (n = 117). We have previously published a detailed description of the study protocol [27] and the results of the primary outcome of the study, moderate-to-vigorous-intensity PA (MVPA) level [28]. Demographic information was obtained at inclusion and obstetric (e.g., gestational diabetes mellitus and gestational hypertensive disorders) and neonatal outcomes (birth weight and birth length) were collected from medical records. Pre-pregnancy BMI (kg/m²) was calculated based on self-reported pre-pregnancy weight and height. GWG at 40+0 weeks gestation was estimated based on predicted body weights from a mixed effects model as previously described [29] and excessive GWG was defined according to the Institute of Medicine’s recommendations [4]. Small for gestational age (< 10th percentile) and large for gestational age (> 90th percentile) [30] were defined according to a Scandinavian reference population and calculated using the Marsal formula [31], which includes fetal sex, birth weight and gestational age at delivery.

Written informed consent was obtained from all participants. The study was approved by the Danish National Committee on Health Research Ethics (August 30, 2018, #H-18011067) and the Danish Data Protection Agency (September 12, 2018, #P-2019-512). The study adheres to the principles of the Helsinki declaration.

Randomization, interventions, and physical activity measures

Randomization in a 1:2:2 ratio to standard care (CON), structured supervised exercise training (EXE), or motivational counselling on PA (MOT) occurred after a one-week baseline period (at latest 16+0 weeks gestation). Participants in the EXE intervention were offered one-hour supervised exercise training at moderate intensity three times per week in a gym and swimming pool. In the MOT intervention, participants were offered three group and four individual PA motivational counselling sessions of 1–2 hours duration during pregnancy and received a weekly personalized text message to increase PA level. Instructors with a bachelor’s or master’s degree in physiotherapy, exercise physiology or similar conducted the intervention activities. During the COVID19-pandemic (from March 11^th, 2020, and throughout the intervention period) EXE and MOT sessions were conducted online using Zoom Cloud Meetings. The EXE group had access to the swimming pool for three months during this period. In a period, test visits were also conducted online and no DLW administration nor DXA scans were performed [27].

PA, including MVPA (min per week), active kilocalories (per day) and steps (per day), were measured continuously from inclusion to delivery by a wrist-worn activity tracker (Garmin Vivosport). Missing PA data due to non-wear time were imputed by multiple imputations in 25 data sets using a prespecified seed, preselected baseline variables (body weight, age, PA, education level, and parity), and the random forest imputation model from the mice R package [28, 32]. PA data used for association analyses included the average imputed values from randomization to 28+6 weeks gestation for analyses with body composition assessed by DLW at 28 weeks gestation, and from randomization to delivery for analyses with body composition assessed by DXA 7–14 days after delivery.

Body composition measurements

Doubly labeled water.

The doubly labeled water technique (DLW) can be used to estimate fat mass based on total body water. In the present study, DLW (Sercon Limited, UK) was orally administered (0.1 g of 99.98% D₂O and 1.6 g of 10% ¹⁸O per kg body weight) at a test visit at 28 weeks gestation after the collection of two baseline urine samples. In the weeks following DLW intake, participants collected urine samples in the morning (not the first void) after 1, 4, 7, 11, and 14 days. Samples were immediately stored in the participant’s own freezer at around -18°C and transported to the hospital for storage at -80°C as soon as possible after day 14. Samples were shipped to the Clinical Metabolomics Core Facility at Rigshospitalet, Copenhagen, for analysis, which is described in detail by Alomairah et al. [33]. The total body water was calculated as the average of H₂ and ¹⁸O dilution space divided by correction factors for in vivo isotopic exchange (1.04 for H₂ and 1.01 for ¹⁸O) [34]. Total fat mass (kg) and fat-free mass (kg) at 28 weeks gestation were calculated from total body water and body weight at DLW administration day, based on equations for no edema or leg edema only [35] and specified to a gestational age of 28 weeks [23]. Fat-free mass is composed of water, protein, and bone minerals. Fat percentage (%) at 28 weeks gestation was calculated from the total fat mass and body weight at DLW administration day.

Dual-energy X-ray absorptiometry scans.

Whole-body composition was measured by DXA scans (Hologic Discovery A/Horizon A, Marlborough, MA, US (n = 115), and GE Healthcare Lunar iDXA, Chicago, IL, US (n = 2)) 7–14 days after delivery at Department of Nuclear Medicine and Clinical Physiology, Copenhagen University Hospital–North Zealand, Hilleroed by trained staff blinded for study group allocation. Body composition measures included fat mass (kg), fat percentage (%), fat-free mass (kg), visceral adipose tissue mass (g), and bone mineral density (g/cm²). Fat-free mass was composed of the sum of lean mass and bone mineral content assessed by DXA.

Statistical analyses

Data are presented as mean and standard deviation for approximately symmetric distributions, median and interquartile range for asymmetric distributions, and frequency and proportion for categorical data. Estimated effect sizes are presented as means with 95% confidence interval [95% CI]. Statistical analyses were performed using R (version 4.1.0) [36] and GraphPad Prism (version 9, GraphPad Software) and statistical significance was defined as a p-value < 0.05. Residuals were checked for normal distribution by visual inspection. One-way ANOVA was used to compare fat mass, fat percentage and fat-free mass (DLW and DXA), as well as visceral adipose tissue mass and bone mineral density (DXA) between the three study groups. Associations between PA measures per se and body composition measures were performed using linear regression with adjustment for pre-pregnancy BMI. Additionally, we performed linear regression analysis to explore the association between maternal pre-pregnancy BMI and MVPA, active kilocalories, as well as steps in the baseline period.

Results

Participant characteristics

The FitMum study included 220 women (219 randomized) and we obtained body composition data from in total 150 participants (CON: n = 28, EXE: n = 59, MOT: n = 63). Urine samples for DLW analyses were available from 134 participants (CON: n = 24, EXE: n = 53, MOT: n = 57) and DXA scans were available from 117 participants (CON: n = 23, EXE: n = 47, MOT: n = 47) (Fig 1).

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Fig 1. Inclusion, randomization, allocation, and analyzed body composition data in the FitMum study.

Body composition data were obtained from 150 participants in total (CON: n = 28, EXE: n = 59, MOT: n = 63). Urine samples for DLW analyses were obtained from n = 24 in CON, n = 53 in EXE and n = 57 in MOT at gestational age 28 weeks. DXA scans carried out 7–14 days after delivery were available from n = 23 in CON, n = 47 in EXE and n = 47 in MOT. Both DLW and DXA data were available from 101 participants. CON; Control, DLW; Doubly labeled water, DXA; Dual-energy X-ray absorptiometry, EXE; Structured supervised exercise training, MOT; Motivational counselling on physical activity. The figure was created with BioRender.com.

https://doi.org/10.1371/journal.pone.0308214.g001

We obtained both DLW and DXA data from 101 out of the 150 participants, whereas only DLW or DXA data was obtained from the remaining 49 participants. Descriptive characteristics of the 150 participants included in the present secondary analyses are shown in Table 1. Most participants were healthy and without obstetric complications, but more than 50% had an excessive GWG according to the Institute of Medicine’s recommendations [4]. Most offspring were delivered full term and had normal anthropometric measures. Descriptive characteristics seemed to be similar between the three study groups except for proportion of nulliparous participants, excessive GWG, infant sex, and proportion of children born either small or large for gestational age. No statistical comparisons have been performed on descriptive characteristics in accordance with CONSORT recommendations.

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Table 1. Descriptive characteristics.

https://doi.org/10.1371/journal.pone.0308214.t001

The descriptive characteristics and the distribution of participants in the three groups for the participants included in the present secondary analyses (n = 150) did not differ compared to the original sample of participants in the study (n = 219) [29]. Among the participants included in the present analyses, the median weekly MVPA from randomization to delivery was 32.5 minutes (min) (21.0–46.2) in CON, 47.1 min (27.5–92.3) in EXE and 31.8 min (21.7–56.8) in MOT. Among the same participants, adherence to EXE and MOT was on average 1.5 exercise sessions/week [1.3;1.7] out of the recommended 3 exercise sessions/week and 6.1 counselling sessions [5.7;6.5] out of the recommended 7 counselling sessions during pregnancy, respectively.

Body composition at 28 weeks gestation and 7–14 days after delivery

We found no difference between the three study groups in total fat mass, fat percentage or fat-free mass as measured by DLW at 28 weeks gestation or by DXA scans 7–14 days after delivery (Table 2). Also, DXA scan measurements 7–14 days after delivery showed no differences between groups in visceral adipose tissue mass and bone mineral density (Table 2).

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Table 2. Body composition at 28 weeks gestation and 7–14 days after delivery.

https://doi.org/10.1371/journal.pone.0308214.t002

Pre-pregnancy body mass index and baseline physical activity

Maternal pre-pregnancy BMI was positively associated with both MVPA (p = 0.006) and active kilocalories (p < 0.001) at baseline, whereas no association was found between pre-pregnancy BMI and steps. Thus, we only report correlations between PA measures per se and body composition measures with adjustment for pre-pregnancy BMI.

Associations between prenatal physical activity and body composition at 28 weeks gestation

Linear regression analyses adjusted for pre-pregnancy BMI showed no associations of MVPA with fat mass, fat percentage, or fat-free mass measured by DLW at 28 weeks gestation (Table 3). Similarly, no associations were found between active kilocalories and fat mass, fat percentage, or fat-free mass (Table 3). In contrast, higher number of steps was associated with lower fat mass (p = 0.026) and fat percentage (p = 0.007), but not with fat-free mass (Table 3).

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Table 3. Associations between prenatal physical activity per se (from randomization to 28+6 weeks gestation) and body composition assessed by doubly labeled water at 28 weeks gestation, adjusted for pre-pregnancy body mass index.

https://doi.org/10.1371/journal.pone.0308214.t003

Associations between prenatal physical activity and body composition 7–14 days after delivery

Linear regression analyses adjusted for pre-pregnancy BMI showed no associations between MVPA and fat mass, fat percentage, fat-free mass, visceral adipose tissue, or bone mineral density assessed by DXA 7–14 days after delivery (Table 4). A positive association was found between active kilocalories and fat-free mass (p = 0.022), but active kilocalories was not associated with other body composition measures (Table 4). In contrast, steps were negatively associated with fat mass (p = 0.002), fat percentage (p = 0.004), and visceral adipose tissue mass (p = 0.004). Steps were not associated with fat-free mass or bone mineral density (Table 4).

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Table 4. Associations between prenatal physical activity per se (from randomization to delivery) and body composition assessed by dual-energy X-ray absorptiometry scan 7–14 days after delivery, adjusted for pre-pregnancy body mass index.

https://doi.org/10.1371/journal.pone.0308214.t004

Discussion

In the present study we found no effects of EXE or MOT during pregnancy on fat mass, fat percentage or fat-free mass at 28 weeks gestation and at 7–14 days after delivery compared to CON. Visceral adipose tissue mass and bone mineral density at 7–14 days after delivery did not differ between groups either. Our findings from linear regression analyses adjusted for pre-pregnancy BMI showed that a higher number of steps per se was associated with lower fat mass, fat percentage, and visceral adipose tissue mass at 28 weeks gestation and 7–14 days after delivery, whereas MVPA and active kilocalories were not. Active kilocalories during pregnancy was however positively associated with fat-free mass 7–14 days after delivery. This association was not observed in relation to the other measures of PA.

Fat mass, fat percentage, and fat-free mass from both DLW and DXA analyses were similar in our and other studies investigating maternal body composition and PA in pregnant women with normal weight [19, 21]. It is noteworthy that our interventions did not improve body composition measures compared to CON. These results are in contrast to some non-randomized controlled studies in pregnant women indicating that higher PA is associated with lower fat mass [18–20]. On the other hand, in line with our results, two previous randomized controlled trials investigating effects of prenatal exercise interventions on maternal body composition showed no effects on fat mass, fat percentage or fat-free mass [21, 22] compared to control groups. The prenatal exercise interventions conducted in these other studies are somewhat comparable to the EXE intervention in the present study, since they consisted of 3–5 exercise sessions per week for 15–50 minutes and the studies included women with normal weight [21] and overweight and obesity [22].

The lack of intervention effects on body composition in the present study might be explained by the low adherence rate and low MVPA level among participants in EXE and MOT, since it is important to achieve a certain amount of PA to obtain beneficial health effects [37, 38]. In both EXE and MOT, the median weekly MVPA level from randomization to delivery was below 60 minutes per week and thus markedly lower than the recommended PA level by the Danish Health Authorities of 210 minutes per week at moderate intensity [37]. The COVID-19 pandemic started during the study conduction period but did not seem to affect PA level negatively in our overall study population (n = 219). For example MVPA did not differ between participants included before the COVID-19 pandemic (physical intervention only) and during the COVID-19 pandemic (online intervention only) in any of the three study groups [28]. Nevertheless, although the PA level among participants in our study was relatively low, it was likely better than what could be expected if the interventions were applied at a population level since we recognize that our study sample is healthy, has a low BMI, no chronic disease indications and might possibly be more motivated to be physically active than women who did not consent for the study.

Another reason for the negative findings in the present study could be that the study might be underpowered to detect differences. The numbers of participants in our study groups (CON: n = 28, EXE: n = 59, MOT: n = 63) were only slightly higher compared to the aforementioned randomized controlled trials by Cavalcante et al. [21] and Seneviratne et al. [22], who found no effects of prenatal exercise training on maternal body composition. Thus, even if assuming that our interventions would be effective on improving maternal body composition had adherence rate and MVPA level been higher, our study might be underpowered to detect effects on maternal fat mass, fat-free mass etc.

Moreover, we have not collected baseline data on maternal body composition specifically, but our data on maternal pre-pregnancy BMI reveal that we included women with relatively normal weight in our study, which might have reduced the potential for exercise to improve body composition compared to for example pregnant populations with overweight and obesity. Conversely, more than 50% of our study participants had an excessive GWG according to the Institute of Medicine’s recommendations [4], which indicates that there could be room for improvement of maternal body composition.

Interestingly, in line with previous studies investigating PA and fat mass in pregnant women [18–20], we found that higher number of daily steps was associated with lower fat content at 28 weeks gestation and 7–14 days after delivery, after adjusting for pre-pregnancy BMI. This is particularly interesting because walking seems to be the preferred PA modality among pregnant women, and it is unique compared to other PA modalities in that it may be more meaningfully integrated into some transportation and occupational activities [39]. In addition, Renault et al. [40] investigated a PA intervention including encouragement to increase number of daily steps in pregnant women with obesity, and found a lower GWG after the PA intervention compared to standard care. Obviously, we cannot conclude causality from our linear regression analysis results. The negative associations between steps and fat measures can express that participants with lower fat content took more daily steps.

Moreover, we found that a higher amount of active kilocalories during pregnancy was associated with higher fat-free mass 7–14 days after delivery. Previously, fat-free mass has also been shown to increase after exercise training in non-pregnant women [41], but to our knowledge, the present study is the first to show that higher prenatal PA in the form of active kilocalories is associated with higher fat-free mass in the early postpartum period.

Strengths and limitations

A strength of the present study was that the effects of prenatal exercise interventions on maternal body composition were investigated in a randomized controlled design obtaining body composition data from a relatively large number of participants.

Moreover, body composition was measured both during pregnancy using DLW and early postpartum by DXA scan. DXA scan is considered a highly accurate method of measuring body composition, and despite this method being unapplicable during pregnancy due to radiation exposure, measurements immediately before conception or after delivery are still considered highly valuable for understanding body composition changes across pregnancy [23, 26]. Further, the use of DLW to assess body composition during pregnancy was a strength of the present study. When using DLW to assess body composition, total body water is measured and used to estimate fat mass and fat-free mass based on assumptions of the hydration of fat-free mass, calculated as the ratio between total body water and fat-free mass. A disadvantage of using DLW during pregnancy to estimate body composition measures is the need to assume the individual hydration of fat-free mass, since fat-free mass hydration changes during pregnancy, which may lead to errors in the body fat estimates [23, 25].

As expected, we found that higher maternal pre-pregnancy BMI was associated with higher MVPA and active kilocalories at baseline. When evaluating associations between PA and body composition in the present study, it was a limitation that the underlying algorithms for activity estimates provided from the commercial Garmin activity tracker are unavailable for researchers. For example, it was unclear how maternal body weight was handled in the algorithm. We assume that the PA estimates derived from the activity tracker were based on the participant’s heart rate measurements, as well as maternal body weight and other data entered in the associated Garmin Connect app, as described previously [33]. We did not find any association between pre-pregnancy BMI and number of daily steps at baseline. Thus, steps might be a more robust measure of PA across different BMI ranges, which could be explained by an assumption that number of daily steps is estimated based on the accelerometer technology in the activity tracker to a higher degree compared to MVPA and active kilocalories.

Conclusions

Neither structured supervised exercise training nor motivational counselling on PA influenced maternal body composition at 28 weeks gestation or 7–14 days after delivery compared to standard care. Interestingly, when adjusted for pre-pregnancy BMI, higher number of daily steps during pregnancy was associated with lower fat content at 28 weeks gestation and 7–14 days after delivery, whereas MVPA and active kilocalories were not. Active kilocalories during pregnancy was however positively associated with fat-free mass 7–14 days after delivery. Low adherence to the interventions and low MVPA level in our study could account for the lack of positive effects of our interventions on maternal body composition outcomes. Future research is needed on novel strategies to improve adherence to PA during pregnancy and maybe even prior to conception.

Supporting information

S1 Checklist. CONSORT 2010 checklist of information to include when reporting a randomised trial*.

https://doi.org/10.1371/journal.pone.0308214.s001

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S1 File.

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S2 File.

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Acknowledgments

The authors would like to acknowledge the participants, research assistants and students who contributed to conduct the intervention activities and data collection. We would also like to thank the technical staff at the Clinical Research Unit, Department of Research (especially Susanne Månsson and Charlotte Pietraszek), and at the Department of Nuclear Medicine and Clinical Physiology, Copenhagen University Hospital–North Zealand, Hilleroed, for their contribution to data collection. Furthermore, we thank Filip Skovgaard Nielsen, Department of Biomedical Sciences, University of Copenhagen, for assistance with preparing DXA scan data for analysis.

References

1. Grieger JA, Hutchesson MJ, Cooray SD, et al. A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum. Ther Adv Reprod Heal. 2021;9(6):259–261. pmid:33615227
- View Article
- PubMed/NCBI
- Google Scholar
2. Goldstein RF, Abell SK, Ranasinha S, et al. Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis. JAMA—J Am Med Assoc. 2017;317(21):2207–2225. pmid:28586887
- View Article
- PubMed/NCBI
- Google Scholar
3. Goldstein R, Abell S, Ranasinha S, et al. Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women. BMC Med. 2018;16(153):1–14. pmid:30165842
- View Article
- PubMed/NCBI
- Google Scholar
4. IOM (Institute of Medicine) and NRC (National Research Council). Weight Gain During Pregnancy: Reexamining the Guidelines.; 2009.
- View Article
- Google Scholar
5. Lof M, Forsum E. Activity pattern and energy expenditure due to physical activity before and during pregnancy in healthy Swedish women. Br J Nutr. 2006;95(2):296–302. pmid:16469145
- View Article
- PubMed/NCBI
- Google Scholar
6. Svensson H, Wetterling L, Bosaeus M, et al. Body fat mass and the proportion of very large adipocytes in pregnant women are associated with gestational insulin resistance. Int J Obes. 2016;40:646–653. pmid:26563815
- View Article
- PubMed/NCBI
- Google Scholar
7. Henriksson P, Sandborg J, Söderström E, et al. Associations of body composition and physical fitness with gestational diabetes and cardiovascular health in pregnancy: Results from the HealthyMoms trial. Nutr Diabetes. 2021;11(1). pmid:34099629
- View Article
- PubMed/NCBI
- Google Scholar
8. Henriksson P, Löf M, Forsum E. Glucose homeostasis variables in pregnancy versus maternal and infant body composition. Nutrients. 2015;7(7):5615–5627. pmid:26184296
- View Article
- PubMed/NCBI
- Google Scholar
9. Eriksson B, Löf M, Olausson H, Forsum E. Body fat, insulin resistance, energy expenditure and serum concentrations of leptin, adiponectin and resistin before, during and after pregnancy in healthy Swedish women. Br J Nutr. 2010;103(1):50–57. pmid:19703326
- View Article
- PubMed/NCBI
- Google Scholar
10. Nguyen G, Hayes L, Ngongalah L, et al. Association between maternal adiposity measures and infant health outcomes: A systematic review and meta-analysis. Obes Rev. 2022;23(10):1–11. pmid:35801513
- View Article
- PubMed/NCBI
- Google Scholar
11. Wang Y, Mao J, Wang W, Qiou J, Yang L, Chen S. Maternal fat free mass during pregnancy is associated with birth weight. Reprod Health. 2017;14(1):47. pmid:28351407
- View Article
- PubMed/NCBI
- Google Scholar
12. Nugraha GI, Heiman H, Alisjahbana A. Intergenerational effects of maternal birth weight, BMI, and body composition during pregnancy on infant birth weight: Tanjungsari Cohort Study, Indonesia. Asia Pac J Clin Nutr. 2017;26(1):S19–S25. pmid:28625032
- View Article
- PubMed/NCBI
- Google Scholar
13. Forsum E, Löf M, Olausson H, Olhager E. Maternal body composition in relation to infant birth weight and subcutaneous adipose tissue. Br J Nutr. 2006;96(2):408–414. pmid:16923238
- View Article
- PubMed/NCBI
- Google Scholar
14. Andersson-Hall UK, Pivodic A, de Maré HK, et al. Infant body composition relationship to maternal adipokines and fat mass: the PONCH study. Pediatr Res. 2021;89(7):1756–1764. pmid:32927470
- View Article
- PubMed/NCBI
- Google Scholar
15. Henriksson P, Löf M, Forsum E. Parental fat-free mass is related to the fat-free mass of infants and maternal fat mass is related to the fat mass of infant girls. Acta Paediatr Int J Paediatr. 2015;104(5):491–497.
- View Article
- Google Scholar
16. Isganaitis E, Venditti S, Matthews TJ, Lerin C, Demerath EW, Fields DA. Maternal obesity and the human milk metabolome: associations with infant body composition and postnatal weight gain. Am J Clin Nutr. 2019;110(1):111–120. pmid:30968129
- View Article
- PubMed/NCBI
- Google Scholar
17. Bzikowska-Jura A, Czerwonogrodzka-Senczyna A, Olędzka G, Szostak-Węgierek D, Weker H, Wesołowska A. Maternal nutrition and body composition during breastfeeding: Association with human milk composition. Nutrients. 2018;10(10). pmid:30262786
- View Article
- PubMed/NCBI
- Google Scholar
18. Andersson-Hall U, de Maré H, Askeli F, Börjesson M, Holmäng A. Physical activity during pregnancy and association with changes in fat mass and adipokines in women of normal-weight or with obesity. Sci Rep. 2021;11(1):1–10.
- View Article
- Google Scholar
19. Sandborg J, Migueles JH, Söderström E, Blomberg M, Henriksson P, Löf M. Physical Activity, Body Composition, and Cardiometabolic Health during Pregnancy: A Compositional Data Approach. Med Sci Sports Exerc. 2022;54(12):2054–2063. pmid:36069838
- View Article
- PubMed/NCBI
- Google Scholar
20. Ferrari N, Bae-Gartz I, Bauer C, et al. Exercise during pregnancy and its impact on mothers and offspring in humans and mice. J Dev Orig Health Dis. 2018;9(1):63–76. pmid:28780912
- View Article
- PubMed/NCBI
- Google Scholar
21. Cavalcante SR, Cecatti JG, Pereira RI, Baciuk EP, Bernardo AL, Silveira C. Water aerobics II: maternal body composition and perinatal outcomes after a program for low risk pregnant women. Reprod Health. 2009;6(1):1–7. pmid:19126239
- View Article
- PubMed/NCBI
- Google Scholar
22. Seneviratne S, Jiang Y, Derraik J, et al. Effects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: a randomised controlled trial. BJOG An Int J Obstet Gynaecol. 2016;123(4):588–597.
- View Article
- Google Scholar
23. Most J, Marlatt KL, Altazan AD, Redman LM. Advances in assessing body composition during pregnancy. Eur J Clin Nutr. 2018;72(5):645–656. pmid:29748651
- View Article
- PubMed/NCBI
- Google Scholar
24. Marshall NE, Murphy EJ, King JC, et al. Comparison of multiple methods to measure maternal fat mass in late gestation. Am J Clin Nutition. 2016;103(4):1055–1063. pmid:26888714
- View Article
- PubMed/NCBI
- Google Scholar
25. Widen EM, Gallagher D. Body composition changes in pregnancy: measurement, predictors and outcomes. Eur J Clin Nutr. 2014;68(6):643–652. pmid:24667754
- View Article
- PubMed/NCBI
- Google Scholar
26. Borga M, West J, Bell JD, et al. Advanced body composition assessment: from body mass index to body composition profiling. J Investig Med. 2018;66:887–895. pmid:29581385
- View Article
- PubMed/NCBI
- Google Scholar
27. Roland CB, Knudsen S de P, Alomairah SA, et al. Structured supervised exercise training or motivational counselling during pregnancy on physical activity level and health of mother and offspring: FitMum study protocol. BMJ Open. 2021;11(3):1–11. pmid:33741668
- View Article
- PubMed/NCBI
- Google Scholar
28. Knudsen S de P, Alomairah SA, Roland CB, et al. Effects of Structured Supervised Exercise Training or Motivational Counseling on Pregnant Women’s Physical Activity Level: FitMum Randomized Controlled Trial. J Med Internet Res. 2022;24(7):1–13. pmid:35857356
- View Article
- PubMed/NCBI
- Google Scholar
29. Roland CB, Knudsen S, Alomairah SA, et al. Effects of prenatal exercise on gestational weight gain, obstetric and neonatal outcomes: FitMum randomized controlled trial. BMC Pregnancy Childbirth. 2023;23(214):1–11. pmid:36991380
- View Article
- PubMed/NCBI
- Google Scholar
30. Feig DS, Corcoy R, Jensen DM, et al. Diabetes in pregnancy outcomes: A systematic review and proposed codification of definitions. Diabetes Metab Res Rev. 2015;31:680–690. pmid:25663190
- View Article
- PubMed/NCBI
- Google Scholar
31. Maršál K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr Int J Paediatr. 1996;85(7):843–848. pmid:8819552
- View Article
- PubMed/NCBI
- Google Scholar
32. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1–67.
- View Article
- Google Scholar
33. Alomairah SA, Knudsen S de P, Roland CB, et al. Methods to Estimate Energy Expenditure, Physical Activity, and Sedentary Time in Pregnant Women: A Validation Study Using Doubly Labeled Water. J Meas Phys Behav. 2023;1(aop):1–11.
- View Article
- Google Scholar
34. Bhutani S. Special Considerations for Measuring Energy Expenditure with Doubly Labeled Water under Atypical Conditions. J Obes Weight Loss Ther. 2015;s5(Suppl 5):1–20. pmid:26962472
- View Article
- PubMed/NCBI
- Google Scholar
35. van Raaij JMA, Peek MEM, Vermaat-Miedema SH, Schonk CM, Hautvast JG. New equations for estimating body fat mass in pregnancy from body density or total body water. Am J Clin Nutr. 1988;48:24–29. pmid:3389327
- View Article
- PubMed/NCBI
- Google Scholar
36. R Core Team. R: A language and environment for statistical computing. 2020. https://www.r-project.org.
- View Article
- Google Scholar
37. Sundhedsstyrelsen. Fysisk Aktivitet for Gravide: Viden Om Sundhed Og Forebyggelse.; 2023.
- View Article
- Google Scholar
38. Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451–1462. pmid:33239350
- View Article
- PubMed/NCBI
- Google Scholar
39. Connolly CP, Conger SA, Montoye AHK, et al. Walking for health during pregnancy: A literature review and considerations for future research. J Sport Heal Sci. 2019;8(5):401–411. pmid:31534815
- View Article
- PubMed/NCBI
- Google Scholar
40. Renault KM, Nørgaard K, Nilas L, et al. The Treatment of Obese Pregnant Women (TOP) study: A randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women. Am J Obstet Gynecol. 2014;210(2):134.e1–134.e9. pmid:24060449
- View Article
- PubMed/NCBI
- Google Scholar
41. Mandrup CM, Egelund J, Nyberg M, et al. Effects of high-intensity training on cardiovascular risk factors in premenopausal and postmenopausal women. Am J Obstet Gynecol. 2017;216(4):384.e1–384.e11. pmid:28024987
- View Article
- PubMed/NCBI
- Google Scholar

[ref1] 1. Grieger JA, Hutchesson MJ, Cooray SD, et al. A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum. Ther Adv Reprod Heal. 2021;9(6):259–261. pmid:33615227
View Article
PubMed/NCBI
Google Scholar

[2] View Article

[3] PubMed/NCBI

[4] Google Scholar

[ref2] 2. Goldstein RF, Abell SK, Ranasinha S, et al. Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis. JAMA—J Am Med Assoc. 2017;317(21):2207–2225. pmid:28586887
View Article
PubMed/NCBI
Google Scholar

[6] View Article

[7] PubMed/NCBI

[8] Google Scholar

[ref3] 3. Goldstein R, Abell S, Ranasinha S, et al. Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women. BMC Med. 2018;16(153):1–14. pmid:30165842
View Article
PubMed/NCBI
Google Scholar

[10] View Article

[11] PubMed/NCBI

[12] Google Scholar

[ref4] 4. IOM (Institute of Medicine) and NRC (National Research Council). Weight Gain During Pregnancy: Reexamining the Guidelines.; 2009.
View Article
Google Scholar

[14] View Article

[15] Google Scholar

[ref5] 5. Lof M, Forsum E. Activity pattern and energy expenditure due to physical activity before and during pregnancy in healthy Swedish women. Br J Nutr. 2006;95(2):296–302. pmid:16469145
View Article
PubMed/NCBI
Google Scholar

[17] View Article

[18] PubMed/NCBI

[19] Google Scholar

[ref6] 6. Svensson H, Wetterling L, Bosaeus M, et al. Body fat mass and the proportion of very large adipocytes in pregnant women are associated with gestational insulin resistance. Int J Obes. 2016;40:646–653. pmid:26563815
View Article
PubMed/NCBI
Google Scholar

[21] View Article

[22] PubMed/NCBI

[23] Google Scholar

[ref7] 7. Henriksson P, Sandborg J, Söderström E, et al. Associations of body composition and physical fitness with gestational diabetes and cardiovascular health in pregnancy: Results from the HealthyMoms trial. Nutr Diabetes. 2021;11(1). pmid:34099629
View Article
PubMed/NCBI
Google Scholar

[25] View Article

[26] PubMed/NCBI

[27] Google Scholar

[ref8] 8. Henriksson P, Löf M, Forsum E. Glucose homeostasis variables in pregnancy versus maternal and infant body composition. Nutrients. 2015;7(7):5615–5627. pmid:26184296
View Article
PubMed/NCBI
Google Scholar

[29] View Article

[30] PubMed/NCBI

[31] Google Scholar

[ref9] 9. Eriksson B, Löf M, Olausson H, Forsum E. Body fat, insulin resistance, energy expenditure and serum concentrations of leptin, adiponectin and resistin before, during and after pregnancy in healthy Swedish women. Br J Nutr. 2010;103(1):50–57. pmid:19703326
View Article
PubMed/NCBI
Google Scholar

[33] View Article

[34] PubMed/NCBI

[35] Google Scholar

[ref10] 10. Nguyen G, Hayes L, Ngongalah L, et al. Association between maternal adiposity measures and infant health outcomes: A systematic review and meta-analysis. Obes Rev. 2022;23(10):1–11. pmid:35801513
View Article
PubMed/NCBI
Google Scholar

[37] View Article

[38] PubMed/NCBI

[39] Google Scholar

[ref11] 11. Wang Y, Mao J, Wang W, Qiou J, Yang L, Chen S. Maternal fat free mass during pregnancy is associated with birth weight. Reprod Health. 2017;14(1):47. pmid:28351407
View Article
PubMed/NCBI
Google Scholar

[41] View Article

[42] PubMed/NCBI

[43] Google Scholar

[ref12] 12. Nugraha GI, Heiman H, Alisjahbana A. Intergenerational effects of maternal birth weight, BMI, and body composition during pregnancy on infant birth weight: Tanjungsari Cohort Study, Indonesia. Asia Pac J Clin Nutr. 2017;26(1):S19–S25. pmid:28625032
View Article
PubMed/NCBI
Google Scholar

[45] View Article

[46] PubMed/NCBI

[47] Google Scholar

[ref13] 13. Forsum E, Löf M, Olausson H, Olhager E. Maternal body composition in relation to infant birth weight and subcutaneous adipose tissue. Br J Nutr. 2006;96(2):408–414. pmid:16923238
View Article
PubMed/NCBI
Google Scholar

[49] View Article

[50] PubMed/NCBI

[51] Google Scholar

[ref14] 14. Andersson-Hall UK, Pivodic A, de Maré HK, et al. Infant body composition relationship to maternal adipokines and fat mass: the PONCH study. Pediatr Res. 2021;89(7):1756–1764. pmid:32927470
View Article
PubMed/NCBI
Google Scholar

[53] View Article

[54] PubMed/NCBI

[55] Google Scholar

[ref15] 15. Henriksson P, Löf M, Forsum E. Parental fat-free mass is related to the fat-free mass of infants and maternal fat mass is related to the fat mass of infant girls. Acta Paediatr Int J Paediatr. 2015;104(5):491–497.
View Article
Google Scholar

[57] View Article

[58] Google Scholar

[ref16] 16. Isganaitis E, Venditti S, Matthews TJ, Lerin C, Demerath EW, Fields DA. Maternal obesity and the human milk metabolome: associations with infant body composition and postnatal weight gain. Am J Clin Nutr. 2019;110(1):111–120. pmid:30968129
View Article
PubMed/NCBI
Google Scholar

[60] View Article

[61] PubMed/NCBI

[62] Google Scholar

[ref17] 17. Bzikowska-Jura A, Czerwonogrodzka-Senczyna A, Olędzka G, Szostak-Węgierek D, Weker H, Wesołowska A. Maternal nutrition and body composition during breastfeeding: Association with human milk composition. Nutrients. 2018;10(10). pmid:30262786
View Article
PubMed/NCBI
Google Scholar

[64] View Article

[65] PubMed/NCBI

[66] Google Scholar

[ref18] 18. Andersson-Hall U, de Maré H, Askeli F, Börjesson M, Holmäng A. Physical activity during pregnancy and association with changes in fat mass and adipokines in women of normal-weight or with obesity. Sci Rep. 2021;11(1):1–10.
View Article
Google Scholar

[68] View Article

[69] Google Scholar

[ref19] 19. Sandborg J, Migueles JH, Söderström E, Blomberg M, Henriksson P, Löf M. Physical Activity, Body Composition, and Cardiometabolic Health during Pregnancy: A Compositional Data Approach. Med Sci Sports Exerc. 2022;54(12):2054–2063. pmid:36069838
View Article
PubMed/NCBI
Google Scholar

[71] View Article

[72] PubMed/NCBI

[73] Google Scholar

[ref20] 20. Ferrari N, Bae-Gartz I, Bauer C, et al. Exercise during pregnancy and its impact on mothers and offspring in humans and mice. J Dev Orig Health Dis. 2018;9(1):63–76. pmid:28780912
View Article
PubMed/NCBI
Google Scholar

[75] View Article

[76] PubMed/NCBI

[77] Google Scholar

[ref21] 21. Cavalcante SR, Cecatti JG, Pereira RI, Baciuk EP, Bernardo AL, Silveira C. Water aerobics II: maternal body composition and perinatal outcomes after a program for low risk pregnant women. Reprod Health. 2009;6(1):1–7. pmid:19126239
View Article
PubMed/NCBI
Google Scholar

[79] View Article

[80] PubMed/NCBI

[81] Google Scholar

[ref22] 22. Seneviratne S, Jiang Y, Derraik J, et al. Effects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: a randomised controlled trial. BJOG An Int J Obstet Gynaecol. 2016;123(4):588–597.
View Article
Google Scholar

[83] View Article

[84] Google Scholar

[ref23] 23. Most J, Marlatt KL, Altazan AD, Redman LM. Advances in assessing body composition during pregnancy. Eur J Clin Nutr. 2018;72(5):645–656. pmid:29748651
View Article
PubMed/NCBI
Google Scholar

[86] View Article

[87] PubMed/NCBI

[88] Google Scholar

[ref24] 24. Marshall NE, Murphy EJ, King JC, et al. Comparison of multiple methods to measure maternal fat mass in late gestation. Am J Clin Nutition. 2016;103(4):1055–1063. pmid:26888714
View Article
PubMed/NCBI
Google Scholar

[90] View Article

[91] PubMed/NCBI

[92] Google Scholar

[ref25] 25. Widen EM, Gallagher D. Body composition changes in pregnancy: measurement, predictors and outcomes. Eur J Clin Nutr. 2014;68(6):643–652. pmid:24667754
View Article
PubMed/NCBI
Google Scholar

[94] View Article

[95] PubMed/NCBI

[96] Google Scholar

[ref26] 26. Borga M, West J, Bell JD, et al. Advanced body composition assessment: from body mass index to body composition profiling. J Investig Med. 2018;66:887–895. pmid:29581385
View Article
PubMed/NCBI
Google Scholar

[98] View Article

[99] PubMed/NCBI

[100] Google Scholar

[ref27] 27. Roland CB, Knudsen S de P, Alomairah SA, et al. Structured supervised exercise training or motivational counselling during pregnancy on physical activity level and health of mother and offspring: FitMum study protocol. BMJ Open. 2021;11(3):1–11. pmid:33741668
View Article
PubMed/NCBI
Google Scholar

[102] View Article

[103] PubMed/NCBI

[104] Google Scholar

[ref28] 28. Knudsen S de P, Alomairah SA, Roland CB, et al. Effects of Structured Supervised Exercise Training or Motivational Counseling on Pregnant Women’s Physical Activity Level: FitMum Randomized Controlled Trial. J Med Internet Res. 2022;24(7):1–13. pmid:35857356
View Article
PubMed/NCBI
Google Scholar

[106] View Article

[107] PubMed/NCBI

[108] Google Scholar

[ref29] 29. Roland CB, Knudsen S, Alomairah SA, et al. Effects of prenatal exercise on gestational weight gain, obstetric and neonatal outcomes: FitMum randomized controlled trial. BMC Pregnancy Childbirth. 2023;23(214):1–11. pmid:36991380
View Article
PubMed/NCBI
Google Scholar

[110] View Article

[111] PubMed/NCBI

[112] Google Scholar

[ref30] 30. Feig DS, Corcoy R, Jensen DM, et al. Diabetes in pregnancy outcomes: A systematic review and proposed codification of definitions. Diabetes Metab Res Rev. 2015;31:680–690. pmid:25663190
View Article
PubMed/NCBI
Google Scholar

[114] View Article

[115] PubMed/NCBI

[116] Google Scholar

[ref31] 31. Maršál K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr Int J Paediatr. 1996;85(7):843–848. pmid:8819552
View Article
PubMed/NCBI
Google Scholar

[118] View Article

[119] PubMed/NCBI

[120] Google Scholar

[ref32] 32. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1–67.
View Article
Google Scholar

[122] View Article

[123] Google Scholar

[ref33] 33. Alomairah SA, Knudsen S de P, Roland CB, et al. Methods to Estimate Energy Expenditure, Physical Activity, and Sedentary Time in Pregnant Women: A Validation Study Using Doubly Labeled Water. J Meas Phys Behav. 2023;1(aop):1–11.
View Article
Google Scholar

[125] View Article

[126] Google Scholar

[ref34] 34. Bhutani S. Special Considerations for Measuring Energy Expenditure with Doubly Labeled Water under Atypical Conditions. J Obes Weight Loss Ther. 2015;s5(Suppl 5):1–20. pmid:26962472
View Article
PubMed/NCBI
Google Scholar

[128] View Article

[129] PubMed/NCBI

[130] Google Scholar

[ref35] 35. van Raaij JMA, Peek MEM, Vermaat-Miedema SH, Schonk CM, Hautvast JG. New equations for estimating body fat mass in pregnancy from body density or total body water. Am J Clin Nutr. 1988;48:24–29. pmid:3389327
View Article
PubMed/NCBI
Google Scholar

[132] View Article

[133] PubMed/NCBI

[134] Google Scholar

[ref36] 36. R Core Team. R: A language and environment for statistical computing. 2020. https://www.r-project.org.
View Article
Google Scholar

[136] View Article

[137] Google Scholar

[ref37] 37. Sundhedsstyrelsen. Fysisk Aktivitet for Gravide: Viden Om Sundhed Og Forebyggelse.; 2023.
View Article
Google Scholar

[139] View Article

[140] Google Scholar

[ref38] 38. Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451–1462. pmid:33239350
View Article
PubMed/NCBI
Google Scholar

[142] View Article

[143] PubMed/NCBI

[144] Google Scholar

[ref39] 39. Connolly CP, Conger SA, Montoye AHK, et al. Walking for health during pregnancy: A literature review and considerations for future research. J Sport Heal Sci. 2019;8(5):401–411. pmid:31534815
View Article
PubMed/NCBI
Google Scholar

[146] View Article

[147] PubMed/NCBI

[148] Google Scholar

[ref40] 40. Renault KM, Nørgaard K, Nilas L, et al. The Treatment of Obese Pregnant Women (TOP) study: A randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women. Am J Obstet Gynecol. 2014;210(2):134.e1–134.e9. pmid:24060449
View Article
PubMed/NCBI
Google Scholar

[150] View Article

[151] PubMed/NCBI

[152] Google Scholar

[ref41] 41. Mandrup CM, Egelund J, Nyberg M, et al. Effects of high-intensity training on cardiovascular risk factors in premenopausal and postmenopausal women. Am J Obstet Gynecol. 2017;216(4):384.e1–384.e11. pmid:28024987
View Article
PubMed/NCBI
Google Scholar

[154] View Article

[155] PubMed/NCBI

[156] Google Scholar

Figures

Abstract

Introduction

Materials and methods

Participants and study design

Randomization, interventions, and physical activity measures

Body composition measurements

Doubly labeled water.

Dual-energy X-ray absorptiometry scans.

Statistical analyses

Results

Participant characteristics

Body composition at 28 weeks gestation and 7–14 days after delivery

Pre-pregnancy body mass index and baseline physical activity

Associations between prenatal physical activity and body composition at 28 weeks gestation

Associations between prenatal physical activity and body composition 7–14 days after delivery

Discussion

Strengths and limitations

Conclusions

Supporting information

S1 Checklist. CONSORT 2010 checklist of information to include when reporting a randomised trial*.

S1 File.

S2 File.

Acknowledgments

References