Physical fitness and maternal body composition indices during pregnancy and postpartum: the GESTAFIT project

For Peer Review Only Physical fitness and maternal body composition indices during pregnancy and postpartum: the GESTAFIT project. Journal: European Journal of Sport Science Manuscript ID Draft Manuscript Type: Original Paper Keywords: Body composition, Bone health, Cardiovascular/Cardiorespiratory, Fitness URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science For Peer Review Only 1Title: Physical fitness and maternal body composition indices during pregnancy and 2postpartum: the GESTAFIT project. 3Running head: Fitness and body composition during gestation and postpartum. Page 1 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 2 4ABSTRACT 5We explored the association of physical fitness (PF) during pregnancy with maternal body 6composition indices along pregnancy and postpartum period. The study comprised 159 7pregnant women (32.9±4.7 years old). Assessments were carried out at the 16th and 34th 8gestational weeks (g.w.) and six weeks postpartum. Cardiorespiratory fitness (CRF), 9muscular strength (absolute and relative values) and flexibility were measured. Body 10 composition indices were obtained by using dual-energy X-ray absorptiometry at 11 postpartum. The results, after adjusting for potential covariates at the 16th g.w., indicated 12 that greater CRF was associated with lower postpartum indices total fat mass, android 13 and gynoid fat mass (all, p<0.05). Greater absolute upper-body muscular strength was 14 associated with greater pre-pregnancy body mass index (BMI), gestational weight gain 15 (GWG); and postpartum indices body weight, BMI, lean mass, fat free mass, fat mass, 16 gynoid fat mass, T-score and Z-score bone mineral density (BMD) (all, p<0.05). Greater 17 upper-body flexibility was associated with lower pre-pregnancy BMI; and postpartum 18 indices body weight, BMI, lean mass, fat free mass, fat mass, android fat mass and gynoid 19 fat mass, and with greater GWG (all, p<0.05). At the 34th g.w., greater CRF was 20 additionally associated with greater postpartum T-score and Z-score BMD (both, p<0.05). 21 In conclusion, this study reveals that greater PF levels, especially during early pregnancy, 22 may promote a better body composition in the postpartum period. Therefore, clinicians 23 and health promoters should encourage women to maintain or improve PF levels from 24 early pregnancy. 25 26 Keywords: Cardiorespiratory fitness; strength; flexibility; bone density; gestation. 27 28 Page 2 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 3 29 HIGHLIGHTS 30 Given that obesity is on the rise today, it is important to find strategies to cope 31 with it, especially during pregnancy. 32 The results of the present study suggest that greater physical fitness during early 33 pregnancy is key to promoting better body composition in the postpartum period. 34 It should be of clinical interest to encourage pregnant women to maintain or 35 improve their physical fitness levels. Page 3 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 4 36 INTRODUCTION 37 The rising prevalence of obesity, particularly among women in childbearing age, is an 38 increasing public health concern1. In fact, in the European region, the current prevalence 39 of maternal obesity ranges from 7 to 37%2. 40 In this context, maternal body composition indices are correlates with maternal and foetal 41 health. For example, excessive gestational weight gain (GWG) has been associated with 42 adverse maternal (such as gestational diabetes, caesarean section) and foetal outcomes 43 (small or large for gestational age and infant mortality)1-4. Therefore, reaching an optimal 44 GWG during the pregnancy course is highly recommended. Furthermore, women tend to 45 retain some of the body fat accumulated during pregnancy at the postpartum period, being 46 heavier at 1 year postpartum compared with their pre-pregnancy body weight2. 47 In addition, maintaining an adequate bone mineral density (BMD) is especially important 48 during pregnancy and breastfeeding, since major changes occur in the maternal calcium 49 homeostasis and bone metabolism in order to fulfil the demand of calcium and 50 phosphorus of the placenta, foetus and breast milk5, 6. 51 In this sense, adequate PF level during pregnancy, through specific physical activity or 52 exercise recommendations7, 8 is a modifiable factor that might be associated with a better 53 body composition and thus, maternal and child’s general health status and well-being1, 2, 54 9. Moreover, it has been suggested that greater PF levels may also have a positive impact 55 on maternal BMD10, 11. Hence, the screening of PF during pregnancy could be an 56 interesting option, especially in women at high risk of excessive GWG or low BMD. 57 Nevertheless, as far as we are aware, whether greater PF levels during pregnancy may 58 influence maternal body composition has not been previously reported. Consequently, the 59 aim of the present research was to study the association of PF during pregnancy with 60 GWG and maternal body fat and BMD in postpartum period. Page 4 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 5 61 METHODS 62 Study design and participants 63 The present cross-sectional study is part of the GESTAFIT project. The complete 64 procedure and the inclusion-exclusion criteria (see Supplementary Table S1) have been 65 published elsewhere12. A total of 159 Spanish pregnant women enrolled in this study in 66 three turns (from November 2015 to April 2018), for feasibility reasons. The participants 67 were recruited by the research team at the 12th gestational weeks (g.w.), during their first 68 gynaecologist check up at the “San Cecilio” University Hospital (Granada, Spain). A 69 written informed consent was signed by all interested participants after being informed 70 about the study aims and procedures. 71 Procedures 72 After the recruitment, participants were invited to take part in the study at the Sport and 73 Health University Research Institute (iMUDS). The assessments were carried out at the 74 16th (±2 g.w.) and 34th g.w. and one month after birth (postpartum period). The 75 assessments were always conducted in 1 day in the same order: firstly, participants filled 76 an auto-administered anamnesis form assessing their sociodemographic and clinical 77 characteristics. Thereafter, each participant performed the PF tests (i.e., back-scratch test, 78 handgrip test, treadmill protocol). 79 Sociodemographic and clinical data 80 Sociodemographic data, including age, number of children, marital status and educational 81 level; and clinical data, including abortions and lactation options (exclusive 82 breastfeeding, mixed feeding or formula feeding) were collected. 83 Body composition indices 84 Pre-pregnancy body weight was self-reported. On the first and second evaluations, body 85 weight and height were assessed using a scale (InBody R20; Biospace, Seoul, Korea) and Page 5 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 6 86 a stadiometer (Seca 22, Hamburg, Germany), respectively. Body mass index (BMI) was 87 calculated as weight (kg) divided by squared height (m2), including pre-pregnancy BMI. 88 Moreover, GWG (kg) was calculated as the weight at the 34th g.w. minus weight at the 89 16th g.w. At the postpartum evaluation, total lean mass, fat mass, fat free mass, android 90 and gynoid fat mass, and BMD of the whole body were measured using a dual-energy x91 ray absorptiometry (DXA) device (Hologic Discovery QDR, Nasdaq: HOLX). Total 92 body BMD was calculated (g/cm2). Bone T-score was defined as the number of standard 93 deviations [SDs] below the mean value of healthy young women, and the bone Z-score 94 was defined as the number of SDs below the mean of healthy women of the same age13. 95 Physical fitness tests 96 Cardiorespiratory fitness (CRF) was evaluated through maternal maximal oxygen intake 97 (VO2max). It was estimated with the Modified Bruce treadmill protocol14, a submaximal, 98 incremental, multistage and continuous treadmill test. The test incorporated progressive 99 increments in the workload and velocity every 3 minutes to determine limits of maximal 100 exertion. Women were asked to walk on the treadmill until the maternal heart rate reached 101 75% of the age-predicted maximal heart rate. If the participant requested to end the 102 treadmill test, then the test was also stopped before reaching the heart rate value. Although 103 submaximal treadmill testing is common and safe during pregnancy14, 15, women were 104 secured with a harness during the test to prevent risk of falls. 105 Upper-body muscular strength was evaluated by handgrip strength, used as a reference to 106 measure global body strength, as described elsewhere16. A digital dynamometer (TKK 107 5101 Grip-D; Takey, Tokyo, Japan) was used. The participants performed the handgrip 108 strength test twice, alternately with both hands. The best value of 2 attempts for each hand 109 was recorded and the average of both hands was used as absolute muscular strength. 110 Relative upper-body muscular strength was calculated as absolute handgrip strength Page 6 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 7 111 divided by their body weight, measured in each assessment, and used in the analyses as 112 recommended to address the confounding of strength by weight status17. 113 Upper-body flexibility was evaluated with the back-scratch test, as a measure of overall 114 shoulder range of motion. The distance between (or overlap of) the middle fingers behind 115 the back was measured with a ruler18. The back-scratch test outcome is positive for higher 116 flexibility (i.e. hands overlapping behind the back) and negative for lower flexibility (i.e. 117 greater distance between middle fingers behind the back). The best score of 2 attempts 118 for each arm was recorded, and the average of both arms was used for the analyses. 119 Statistical analyses 120 All analyses were performed using the SPSS (IBM SPSS Statistics for Windows, version 121 22.0, Armonk, NY) and the level of significance was set at p<0.05. Descriptive statistics 122 [(mean and standard deviation (SD) for quantitative variables, and the number of women 123 (%) for categorical variables)] were used to describe baseline characteristics of the 124 participants. Linear regression analyses were performed to explore the independent 125 association of CRF, muscular strength, and flexibility as predictors, with different 126 maternal body composition outcomes (dependent variables). Each set, separately, 127 examined the relationship between one predictor and one body composition outcome. 128 These predictors were explored in two models based on the period evaluated: First, values 129 of the PF tests evaluated at the 16th g.w. were introduced as predictors of maternal 130 outcomes. Second, values of the PF tests evaluated at the 34th g.w. were introduced as 131 predictors of maternal outcomes, when applicable. The relative upper-body muscular 132 strength, rather than absolute strength, as previously recommended17, was the chosen 133 muscular strength predictor. Two models were tested. Model I was unadjusted. Model II 134 was controlled for maternal age. Bone health outcomes were further adjusted for pre135 pregnancy BMI (Model II), as a possible confounder10. Since in the GESTAFIT project12 Page 7 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 8 136 a concurrent physical exercise program was carried out until delivery, values at the 34th 137 g.w. (Model II) were additionally adjusted for the exercise intervention (control or 138 intervention group), in order to correct the possible effect of the exercise program on these 139 variables. 140 RESULTS 141 The final sample size was composed of 159 Spanish pregnant women. Nonetheless, some 142 of them did not attend the second (at the 34th g.w.) or last evaluation (postpartum) or did 143 not return all the questionnaires duly completed, which meant a loss of data in some 144 outcomes (Supplementary Figure S1). 145 The sociodemographic and clinical characteristics of the participants are shown in 146 Supplementary Table S2. The mean age of the women at the recruitment was 32.9±4.6 147 years old. Most of them were nulliparous (61%) and opted for exclusive breastfeeding 148 (>66%). 149 The maternal body composition indices and the PF tests of the participants are shown in 150 Table 1. Briefly, women’s BMI was 24.2 kg/m2 during the pre-pregnancy period, and 151 >25.0 kg/m2 at the 16th g.w. and during the postpartum period. Women’s GWG at the 34th 152 g.w. was about 9 kg. Participants’ total BMD was 1.06±0.1 g/cm2 and their bone T-score 153 status was -0.6±1.0 at the postpartum period. Type of lactation (breastfeeding exclusively, 154 mixed or artificial lactation) was additionally included as a potential confounder in bone 155 health outcomes. However, this data no longer changed these results (data not shown). 156 The linear regression model assessing the associations of PF tests at the 16th g.w. with 157 maternal body composition indices is shown in Table 2. 158 In the adjusted model (Model II), greater CRF was associated with lower total fat mass, 159 android fat mass, and gynoid fat mass at postpartum (β ranging from -0.230 to -0.311; all, 160 p<0.05). Greater absolute upper-body muscular strength was associated with greater prePage 8 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only 15 311 2. 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Maternal and Child Health Journal. 403 2014;18(7):1667-74. 404 34. Most J, Marlatt KL, Altazan AD, Redman LM. Advances in assessing body composition 405 during pregnancy. European journal of clinical nutrition. 2018;72(5):645-56. 406 Page 16 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Table 1. Body composition indices and physical fitness levels of the participants Maternal outcomes n Mean±SD Height (cm) 157 163±6.21 Weight previous to pregnancy (Kg) 145 65.1±12.3 Pre-pregnancy body mass index (Kg/m2) 145 24.2±4.2 Values at 16th g.w. Weight at 16th g. w. (Kg) 157 67.0±11.8 Body mass index at 16th g.w. (Kg/m2) 157 25.0±4.1 Values at 34th g.w. Weight at 34th g. w. (Kg) 123 74.6±10.8 Weight gain (16th g.w. to 34th g.w.) (Kg) 121 8.7±3.4 Weight and body composition at postpartum Weight at postpartum (Kg) 107 68.5±11.4 Body mass index at postpartum (Kg/m2) 107 25.5±4.4 Total body fat free mass (Kg) 110 40.9±4.7 Total body lean mass at postpartum (Kg) 110 38.9±4.7 Total body fat mass at postpartum (Kg) 110 26.2±7.7 Total body android fat mass at postpartum (Kg) 110 18.8±0.8 Total body gynoid fat mass at postpartum (Kg) 110 52.1±1.3 Total bone mineral density (g/cm2) 1.06±0.1 Bone mineral density T-score* -0.6±1.0 Bone mineral density Z-score -0.7±0.9 Physical fitness tests Mean±SD 16th g. w. 157 Cardiorespiratory fitness (75% VO2max) Upper-body absolute muscular strength; kg/weight(kg) 27.3±4.3 Upper-body relative muscular strength; kg/weight(kg) 0.4±0.1 Upper-body flexibility (cm) 4.1±6.2 34th g. w. 123 Cardiorespiratory fitness (75% VO2max) Upper-body absolute muscular strength; kg/weight(kg) 27.2±4.5 Upper-body relative muscular strength; kg/weight(kg) 0.4±0.1 Upper-body flexibility (cm) 3.9±6.0 SD, Standard Deviation; g. w., gestational week. *Normal bone is defined as a Tscore of −1.0 or higher, osteopenia is defined as between −1.0 and −2.5, osteoporosis is defined as −2.5 or lower18. Page 17 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Table 2. Linear regression coefficients assessing the association of the physical fitness tests measured at the 16th gestational week with maternal body composition and bone health status Model I Model II Standardized Coefficients (β) Confidence interval 95% (B) p Standardized Coefficients (β) Confidence interval 95% (B) p Cardiorespiratory fitness Pre-pregancy BMI (kg/m2) -0.145 -0.112 (-0.252, -0.029) 0.119 -0.140 -0.108 (-0.249, 0.034) 0.134 GWG (kg) 0.095 0.052 (-0.059, 0.163) 0.352 0.099 0.054 (-0.056, 0.165) 0.331 Weight postpartum (kg) -0.100 -0.183 (-0.578, 0.212) 0.359 -0.093 -0.170 (-0.563, 0.222) 0.391 BMI postpartum (kg/m2) -0.147 -0.110 (-0.270, 0.051) 0.178 -0.141 -0.105 (-0.265, 0.055) 0.195 Total lean mass at postpartum (Kg) 0.021 0.015 (-0.143, 0.173) 0.848 0.024 0.018 (-0.139, 0.175) 0.819 Total fat free mass at postpartum (Kg) 0.016 0.012 (-0.149, 0.174) 0.881 0.020 0.015 (-0.146, 0.176) 0.853 Total fat mass at postpartum (Kg) -0.255 -0.317 (-0.573, -0.060) 0.016 -0.311 -0.250 (-0.563, -0.059) 0.016 Total android fat mass at postpartum (Kg) -0.234 -0.029 (-0.055, -0.003) 0.027 -0.230 -0.029 (-0.054, -0.003) 0.028 Total gynoid fat mass at postpartum (Kg) -0.239 -0.054 (-0.100, -0.007) 0.024 -0.234 -0.052 (-0.098, -0.007) 0.024 Total BMD at postpartum (g/cm2)* -0.070 -0.001 (-0.004, 0.002) 0.515 -0.036 -0.000 (-0.003, 0.002) 0.751 T-score BMD at postpartum* 0.045 0.007 (-0.027, 0.041) 0.674 0.095 0.016 (-0.020, 0.052) 0.388 Z-score BMD at postpartum* 0.052 0.008 (-0.024, 0.039) 0.631 0.104 0.016 (-0.017, 0.049) 0.346 Absolute upper-body strength Pre-pregancy BMI (kg/m2) 0.197 0.192 (0.031, 0.352) 0.019 0.203 0.197 (0.037, 0.357) 0.016 GWG (kg) 0.185 0.160 (0.005, 0.315) 0.043 0.184 0.159 (0.004, 0.315) 0.044 Weight postpartum (kg) 0.324 0.987 (0.428, 1.545) 0.001 0.311 0.947 (0.393, 1.501) 0.001 BMI postpartum (kg/m2) 0.288 0.339 (0.121, 0.557) 0.003 0.277 0.327 (0.109, 0.544) 0.004 Total lean mass at postpartum (Kg) 0.451 0.561 (0.349, 0.772) <0.001 0.438 0.544 (0.334, 0.755) <0.001 Total fat free mass at postpartum (Kg) 0.457 0.580 (0.364, 0.796) <0.001 0.444 0.564 (0.350, 0.779) <0.001 Total fat mass at postpartum (Kg) 0.216 0.446 (0.062, 0.829) 0.023 0.200 0.411 (0.032, 0.791) 0.034 Total android fat mass at postpartum (Kg) 0.160 0.034 (-0.006, 0.073) 0.095 0.146 0.031 (-0.009, 0.070) 0.126 Total gynoid fat mass at postpartum (Kg) 0.210 0.075 (0.008, 0.142) 0.028 0.190 0.068 (0.003, 0.133) 0.042 Total BMD at postpartum (g/cm2)* 0.161 0.003 (-0.001, 0.007) 0.092 0.185 0.004 (0.000, 0.008) 0.068 T-score BMD at postpartum* 0.300 0.075 (0.030, 0.121) 0.001 0.300 0.075 (0.027, 0.124) 0.002 Z-score BMD at postpartum* 0.309 0.072 (0.030, 0.114) 0.001 0.308 0.072 (0.027, 0.117) 0.002 Upper-body flexibility Pre-pregancy BMI (kg/m2) -0.416 -0.287 (-0.392,-0.182) <0.001 -0.414 -0.285 (-0.390,-0.180) <0.001 GWG (kg) 0.274 0.153 (0.055, 0.252) 0.003 0.277 0.155 (0.056, 0.254) 0.002 Weight postpartum (kg) -0.355 -0.644 (-0.973, -0.314) <0.001 -0.352 -0.638 (-0.964, -0.313) <0.001 BMI postpartum (kg/m2) -0.444 -0.311 (-0.434, -0.189) <0.001 -0.442 -0.310 (-0.431, -0.189) <0.001 Total lean mass at postpartum (Kg) -0.274 -0.202 (-0.339, -0.066) 0.004 -0.269 -0.199 (-0.334, -0.064) 0.004 Total fat free mass at postpartum (Kg) -0.269 -0.203 (-0.342, -0.064) 0.005 -0.265 -0.200 (-0.338, -0.061) 0.005 Total fat mass at postpartum (Kg) -0.336 -0.415 (-0.637, -0.192) <0.001 -0.331 -0.408 (-0.626, -0.189) <0.001 Total android fat mass at postpartum (Kg) -0.338 -0.042 (-0.065, -0.020) <0.001 -0.333 -0.042 (-0.064, -0.019) <0.001 Total gynoid fat mass at postpartum (Kg) -0.253 -0.054 (-0.094, -0.015) 0.008 -0.246 -0.053 (-0.091, -0.014) 0.008 Total BMD at postpartum (g/cm2)* -0.043 -0.001 (-0.003, 0.002) 0.657 -0.025 -0.000 (-0.003, 0.002) 0.821 T-score BMD at postpartum* -0.198 -0.029 (-0.057, -0.002) 0.039 -0.195 -0.030 (-0.062, -0.003) 0.072 Z-score BMD at postpartum* -0.197 -0.027 (-0.053, -0.001) 0.040 -0.195 -0.028 (-0.058, -0.003) 0.074 BMI, body mass index; GWG, gestational weight gain; BMD, bone mineral density; β, standardized regression coefficient; B, non-standardized regression coefficient. Bold values, p<0.05. Model I was unadjusted. Model II was adjusted for maternal age. *Model II additionally adjusted for pre-pregnancy body mass index. Page 18 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Table 3. Linear regression coefficients assessing the association of the physical fitness tests measured at the 34th gestational week with maternal body composition and bone health status Model I Model II Standardized Coefficients (β) Confidence interval 95% (B) p Standardized Coefficients (β) Confidence interval 95% (B) p Cardiorespiratory fitness Weight postpartum (kg) -0.152 -0.359 (-0.877, 0.160) 0.173 -0.115 -0.270 (-0.788, 0.247) 0.302 BMI postpartum (kg/m2) -0.207 -0.229 (-0.404, -0.011) 0.039 -0.194 -0.176 (-0.373, 0.021) 0.079 Total lean mass at postpartum (Kg) 0.029 0.027 (-0.173, 0.227) 0.791 0.085 0.079 (-0.120, 0.278) 0.433 Total fat free mass at postpartum (Kg) 0.033 0.032 (-0.174, 0.237) 0.761 0.088 0.083 (-0.122, 0.288) 0.422 Total fat mass at postpartum (Kg) -0.324 -0.522 (-0.854, -0.191) 0.002 -0.290 -0.467 (-0.801, -0.134) 0.007 Total android fat mass at postpartum (Kg) -0.329 -0.055 (-0.089, -0.021) 0.002 -0.293 -0.049 (-0.084, -0.015) 0.006 Total gynoid fat mass at postpartum (Kg) -0.318 -0.087 (-0.143, -0.031) 0.003 -0.294 -0.081 (-0.138, -0.024) 0.006 Total BMD at postpartum (g/cm2)* 0.127 0.002 (-0.001, 0.005) 0.244 0.207 0.003 (0.000, 0.007) 0.078 T-score BMD at postpartum* 0.141 0.027 (-0.014, 0.067) 0.196 0.233 0.045 (0.001, 0.090) 0.047 Z-score BMD at postpartum* 0.130 0.023 (-0.015, 0.060) 0.232 0.228 0.041 (0.000, 0.083) 0.053 Absolute upper-body strength Weight postpartum (kg) 0.184 0.487 (-0.022, 0.997) 0.061 0.184 0.489 (-0.019, 0.996) 0.059 BMI postpartum (kg/m2) 0.122 0.125 (-0.074, 0.323) 0.215 0.121 0.124 (-0.075, 0.323) 0.221 Total lean mass at postpartum (Kg) 0.364 0.391 (0.199, 0.583) <0.001 0.369 0.397 (0.206, 0.587) <0.001 Total fat free mass at postpartum (Kg) 0.369 0.406 (0.210, 0.602) <0.001 0.374 0.412 (0.217, 0.606) <0.001 Total fat mass at postpartum (Kg) 0.075 0.134 (-0.208, 0.475) 0.440 0.069 0.123 (-0.217, 0.462) 0.476 Total android fat mass at postpartum (Kg) 0.023 0.004 (-0.031, 0.039) 0.808 0.022 0.004 (-0.031, 0.039) 0.822 Total gynoid fat mass at postpartum (Kg) 0.083 0.026 (-0.033, 0.085) 0.390 0.067 0.021 (-0.038, 0.079) 0.484 Total BMD at postpartum (g/cm2)* 0.163 0.003 (0.000, 0.006) 0.090 0.165 0.003 (-0.001, 0.006) 0.100 T-score BMD at postpartum* 0.276 0.060 (0.020, 0.100 0.004 0.266 0.057 (0.016, 0.098) 0.006 Z-score BMD at postpartum* 0.284 0.057 (0.020, 0.095) 0.003 0.274 0.055 (0.017, 0.093) 0.005 Upper-body flexibility Weight postpartum (kg) -0.309 -0.562 (-0.901, -0.223) 0.001 -0.308 -0.561 (-0.896, -0.225) 0.001 BMI postpartum (kg/m2) -0.394 -0.277 (-0.403, -0.151) <0.001 -0.394 -0.277 (-0.403, -0.151) <0.001 Total lean mass at postpartum (Kg) -0.166 -0.125 (-0.268, 0.018) 0.085 -0.162 -0.122 (-0.264, 0.019) 0.089 Total fat free mass at postpartum (Kg) -0.160 -0.123 (-0.270, -0.023) 0.097 -0.156 -0.121 (-0.266, -0.024) 0.101 Total fat mass at postpartum (Kg) -0.342 -0.429 (-0.655, -0.203) <0.001 -0.341 -0.428 (-0.650, -0.205) <0.001 Total android fat mass at postpartum (Kg) -0.339 -0.043 (-0.066, -0.020) <0.001 -0.337 -0.043 (-0.066, -0.020) <0.001 Total gynoid fat mass at postpartum (Kg) -0.320 -0.070 (-0.109, -0.030) 0.001 -0.322 -0.070 (-0.109, -0.032) <0.001 Total BMD at postpartum (g/cm2)* 0.045 0.001 (-0.002, 0.003) 0.642 0.125 0.002 (-0.001, 0.004) 0.242 T-score BMD at postpartum* -0.095 -0.015 (-0.044, -0.015) 0.326 -0.050 -0.008 (-0.042, -0.025) 0.632 Z-score BMD at postpartum* -0.099 -0.014 (-0.041, -0.013) 0.308 -0.057 -0.009 (-0.040, -0.023) 0.590 BMI, body mass index; GWG, gestational weight gain; BMD, bone mineral density; β, standardized regression coefficient; B, non-standardized regression coefficient. Bold values, p<0.05. Model I was unadjusted. Model II was adjusted for maternal age, and exercise intervention at the 34th gestational week. *Model II additionally adjusted for pre-pregnancy body mass index. Page 19 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Table 4. Linear regression coefficients assessing the association of the relative upper-body strength measured at the 16th and 34th gestational week with maternal body composition and bone health status Model I Model II Standardized Coefficients (β) Confidence interval 95% (B) p Standardized Coefficients (β) Confidence interval 95% (B) p Relative upper-body strength (16th gestational week) Pre-pregancy BMI (kg/m2) -0.639 -32.310 (-38.840, -25.780) <0.001 -0.641 -32.453 (-39.101, -25.804) <0.001 GWG (kg) 0.271 12.266 (4.324, 20.208) 0.003 0.283 12.801 (4.793, 20.808) 0.002 Weight postpartum (kg) -0.561 -89.624 (-115.483, -63.764) <0.001 -0.546 -87.316 (-113.060, -61.571) <0.001 BMI postpartum (kg/m2) -0.498 -30.771 (-41.240, -20.301) <0.001 -0.487 -30.074 (-40.565, -19.582) <0.001 Total lean mass at postpartum (Kg) -0.353 -22.978 (-34.688, -11.269) <0.001 -0.340 -22.132 (-33.750, -10.513) <0.001 Total fat free mass at postpartum (Kg) -0.350 -23.219 (-35.198, -11.241) <0.001 -0.337 -22.384 (-34.282, -10.486) <0.001 Total fat mass at postpartum (Kg) -0.575 -61.829 (-78.782, -44.876) <0.001 -0.561 -60.377 (-77.089, -43.666) <0.001 Total android fat mass at postpartum (Kg) -0.553 -6.035 (-7.788, -4.283) <0.001 -0.542 -5.915 (-7.656, -4.173) <0.001 Total gynoid fat mass at postpartum (Kg) -0.504 -9.375 (-12.473, -6.278) <0.001 -0.487 -9.064 (-12.092, -6.037) <0.001 Total BMD at postpartum (g/cm2)* 0.055 0.054 (-0.138, 0.246) 0.579 0.080 0.083 (-0.177, 0.344) 0.528 T-score BMD at postpartum* 0.011 0.138 (-2.374, 2.649) 0.914 0.153 2.033 (-1.226, 5.291) 0.219 Z-score BMD at postpartum* 0.017 0.206 (-2.127, 2.539) 0.862 0.163 2.006 (-1.029, 5.040) 0.193 Relative upper-body strength (34th gestational week) Weight postpartum (kg) -0.529 -92.112 (-121.104, -63.120) <0.001 -0.516 -89.762 (-118.898, -60.627) <0.001 BMI postpartum (kg/m2) -0.501 -33.649 (-45.056, -22.241) <0.001 -0.493 -33.087 (-44.614, -21.560) <0.001 Total lean mass at postpartum (Kg) -0.291 -20.447 (-33.402, -7.493) 0.002 -0.271 -19.074 (-32.048, -6.100) 0.004 Total fat free mass at postpartum (Kg) -0.286 -20.522 (-33.780, -7.264) 0.003 -0.267 -19.182 (-32.477, -5.887) 0.005 Total fat mass at postpartum (Kg) -0.597 -69.942 (-88.045, -51.839) <0.001 -0.586 -68.687 (-86.736, -50.637) <0.001 Total android fat mass at postpartum (Kg) -0.562 -6.689 (-8.583, -4.795) <0.001 -0.551 -6.560 (-8.466, -4.654) <0.001 Total gynoid fat mass at postpartum (Kg) -0.553 -11.237 (-14.501, -7.974) <0.001 -0.546 -11.104 (-14.309, -7.899) <0.001 Total BMD at postpartum (g/cm2)* 0.058 0.065 (-0.152, 0.282) 0.554 0.139 0.155 (-0.116, 0.427) 0.260 T-score BMD at postpartum* 0.032 0.449 (-2.287, 3.186) 0.746 0.181 2.564 (-0.809, 5.937) 0.135 Z-score BMD at postpartum* 0.035 0.465 (-2.077, 3.007) 0.717 0.185 2.422 (-0.726, 5.571) 0.130 Page 20 of 20 URL: http:/mc.manuscriptcentral.com/tejs Email: [email protected] European Journal of Sport Science 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60