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
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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
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 ••••••••••••••••••••
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%
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
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.
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
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
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.
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.
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)
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)
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.
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)
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!
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
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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