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j.midw.2017.10.012

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Author’s Accepted Manuscript
The Relationship between Antenatal Body
Attitudes, Pre-Pregnancy Body Mass Index, and
Gestational Weight Gain
Bianca Andrews, Briony Hill, Helen Skouteris
www.elsevier.com/locate/midw
PII:
DOI:
Reference:
S0266-6138(17)30103-1
https://doi.org/10.1016/j.midw.2017.10.012
YMIDW2121
To appear in: Midwifery
Received date: 13 February 2017
Revised date: 8 October 2017
Accepted date: 14 October 2017
Cite this article as: Bianca Andrews, Briony Hill and Helen Skouteris, The
Relationship between Antenatal Body Attitudes, Pre-Pregnancy Body Mass
Index,
and
Gestational
Weight
Gain, Midwifery,
https://doi.org/10.1016/j.midw.2017.10.012
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The Relationship between Antenatal Body Attitudes, Pre-Pregnancy Body Mass Index, and
Gestational Weight Gain
Bianca ANDREWS, BSocSc (Psychology & Forensic Science), Briony HILL, PhD*, Helen
SKOUTERIS, PhD
School of Psychology, Deakin University, Locked Bag 20000, Geelong, Australia, 3220
*Corresponding author. Dr Briony Hill. School of Psychology, Deakin University, Locked
Bag 20000, Geelong, Australia, 3220. Ph: +613 9244 6538. briony.hill@deakin.edu.au
Abstract
Objectives
An estimated 50% of women experience excessive gestational weight gain (GWG). Maternal
body attitudes are associated with GWG, however this relationship is complex and may differ
based on pre-pregnancy body mass index (BMI) or gestational age. The aim of this study was
to explore the moderating role of maternal pre-pregnancy BMI on the relationship between
body attitudes in early-to-mid and late pregnancy and GWG.
Design/Participants
Pregnant women less than 18 weeks gestation were recruited for a postal questionnaire study
via Australian pregnancy online forums, pregnancy and parenting magazines, and antenatal
clinics. In early-mid pregnancy (Time 1; mean (M) = 16.81 weeks gestation, standard
deviation (SD) = 1.18), participants reported demographics, pre-pregnancy weight, height,
and body attitudes (salience of weight and shape, attractiveness, strength and fitness and
feeling fat). In late pregnancy, body attitudes (Time 2; M = 32.65 weeks gestation, SD =
0.91) and weight (Time 3; M = 37.15 weeks gestation, SD = 1.55) were reported. Prepregnancy BMI and total GWG were calculated. Moderation analyses were conducted.
Findings
In early-mid pregnancy, pre-pregnancy BMI moderated the relationship between feeling fat
and GWG. Pre-pregnancy BMI did not moderate the relationship between body attitudes and
GWG for salience of weight and shape, attractiveness or strength and fitness in early-mid
1
pregnancy. In late pregnancy, pre-pregnancy BMI moderated the relationship between all
four body attitude facets (salience of weight and shape, attractiveness, feeling fat and strength
and fitness) and GWG.
Conclusion/Implications for practice
The relationship between body attitudes and GWG was moderated by pre-pregnancy BMI,
particularly in late pregnancy. It is recommended that antenatal health care providers monitor
women’s body attitudes throughout pregnancy to aid in the management of healthy GWG and
promote positive maternal and infant health outcomes. This is particularly important for
women entering pregnancy with an underweight/normal weight BMI.
Keywords
Body image; gestational weight gain; body mass index
INTRODUCTION
An estimated 50% of women across all pre-pregnancy body mass index (BMI)
categories exceed pregnancy weight gain recommendations, defined as BMI-specific weight
gain exceeding internationally recognised cut offs (Institute of Medicine [IOM], 2007; IOM,
2009). Excessive gestational weight gain (GWG) places the mother at increased risk of
gestational hypertension, caesarean delivery, preeclampsia (Haugen et al., 2014), post-partum
weight retention (Siega-Riz et al., 2010; Amorim et al, 2007), obesity, and diabetes (Al
Mamun et al., 2013). In addition, excessive GWG is associated with increased risk of infant
macrosomia (IOM, 2007), and offspring obesity throughout childhood and into adulthood
(Schack-Nielsen et al., 2010).
Maternal body image has been shown to influence weight gain during pregnancy.
Body image is defined as the internal representation an individual has of his or her own outer
appearance (Thompson et al., 1999). Body image can be delineated in many ways, often as
body dissatisfaction (“the negative self-evaluation of bodily size, shape, weight and
musculature”; Joseph et al., 2016, p. 216-217) or body attitudes (an attitudinal aspect of body
image that is reflected in positive or negative affect, cognitions and behaviour towards ones’
body; McArthur et al., 2005; Brown et al., 1990). The nature of the relationship between
body image and GWG appears to be complex and multifactorial (Hill et al., 2013; Sui et al.,
2013). For instance, several studies have found that body dissatisfaction and negative weight
gain attitudes were associated with higher GWG (DiPietro et al., 2003; Sui et al., 2013).
2
Similarly, the findings of a recent systematic review seeking to summarise the relationship
between psychological factors and trimester-specific GWG also revealed that negative body
image and negative weight gain attitudes were a risk factor for excessive GWG (Kapadia et
al., 2015). However, contrary to these findings, it has been reported that specific aspects of
body image, such as feeling fat in late pregnancy and feeling attractive in mid-pregnancy are
associated with lower GWG (Hill et al., 2013).
Explanations for the conflicting associations between body image and GWG should
be explored. One such theory may be that the relationship between body image and GWG
differs based on a woman’s pre-pregnancy BMI; that is, BMI is a moderator of the
relationships between body image and GWG. Due to more restrictive weight gain
recommendations for overweight and obese women, women entering pregnancy with a
higher BMI are more likely to gain weight excessively (IOM, 2009; Hill et al., 2013), despite
lower total mean GWG (Daemers et al., 2013). In non-pregnant populations, BMI and body
image are consistently related, such that BMI has been shown to be associated with several
facets of body image among women: body dissatisfaction and perceptions of being too fat
(Algars, 2009). In fact, higher BMI has been consistently associated with increased body
dissatisfaction (Algars, 2009; Eisenberg et al., 2006; Van der Berg et al., 2007).
In pregnancy, few studies have investigated pre-pregnancy BMI in addition to both
body image and GWG. In one study, it was found that increased distress about pregnancy
weight gain was associated with higher pre-pregnancy BMI, larger GWG and greater body
dissatisfaction (Walker, 1998). More specifically, Copper et al. (1995) found that obese
women (BMI > 26.6) were more likely to hold negative attitudes towards weight gain during
pregnancy, while thin women (BMI < 19.6) were more likely to hold positive weight gain
attitudes.1 Furthermore, discrepancy between current and ideal body shape has been
associated with excessive GWG such that women with a higher BMI with a preference to be
thinner are less likely to gain excessive GWG, while women with a higher BMI who
preferred to be heavier are at an increased risk of excessive GWG (Mehta et al., 2011).
Interestingly, despite the increasing knowledge that body image is an important
consideration during pregnancy (Hill et al., 2013), and well-established rates of high prepregnancy BMI, and excessive GWG (IOM, 2009), to our knowledge, no study has explored
1
It should be noted that the BMI classifications used by Copper et al. (1995) differ from current international
categorisations of BMI (World Health Organisation, 2000), with Copper et al.’s classifications for obese women
most closely aligning with the current overweight (BMI 25.0-29.9 kg/m2) and obese (BMI ≥ 30 kg/m2)
categories, and ‘thin’ women most closely aligning with the current underweight classification (BMI < 18.5
kg/m2).
3
whether pre-pregnancy BMI moderates the relationship between antenatal body image and
GWG. Further exploration into the mechanisms of the inter-relations between these three
factors is required to better understand contributors to excessive GWG. This may aid in the
development of suitable and effective interventions to promote healthy BMI, GWG and
positive body image during pregnancy. Therefore, the aim of this study was to explore the
moderating role of maternal pre-pregnancy BMI on the relationship between body attitudes in
early-to-mid and late pregnancy (specifically salience of weight and shape, attractiveness,
strength and fitness and feeling fat), and GWG.
METHODS
Participant Recruitment and Enrolment
After approval from the XXXX, the study was advertised on Australian pregnancy
online forums, pregnancy and parenting magazines from February 2010 to July 2012, and a
maternity clinic at a large tertiary hospital in Melbourne, Australia from December 2011 to
January 2013. Eligible women were over 18 years of age, pregnant, and between 10 and 18
weeks gestation. Twin pregnancies were excluded.
Procedure
This study was part of a larger study exploring the wellbeing of mothers and their
infants from early-mid pregnancy up to 12 months post-birth. Only data pertaining to
pregnancy were used for the current study. Specifically, after written, voluntary informed
consent was obtained, participants were asked to complete questionnaires which were mailed
out to their homes and returned using the provided replied paid envelopes. For the current
study, questionnaires completed at 16 to 18 (T1), 32 (T2) and 36 weeks gestation (T3) were
used. Participants were asked to complete questionnaires within one to two weeks of the
desired gestational age and indicate their actual gestational age at time of completion.
Questionnaires collected demographic information including age, family income, education,
and parity, as well as information regarding maternal and infant health and wellbeing.
Maternal weight at time of completion of each questionnaire was collected, as were method
of weight and height measurement.
Measures
Pre-Pregnancy BMI.
4
At T1, participants were asked to self-report their height and weight at one month
prior to their pregnancy. Pre-pregnancy BMI was then calculated by dividing pre-pregnancy
weight (kg) by the square of height (m).
Gestational Weight Gain.
Total GWG was calculated by subtracting self-reported pre-pregnancy weight
(collected at T1) from the pregnancy weight reported at T3. Participants were asked to
indicate whether the measurement was taken by their midwife/obstetrician/doctor, or if they
weighed themselves. Total GWG and pre-pregnancy BMI were then used to classify women
according to the 2009 IOM recommendations for weight gain during pregnancy, where it is
recommended that women who are classified as underweight (BMI <18.5) gain 12.5 to 18 kg,
women who are normal weight (BMI 18.5–24.9) gain 11.5 to 16 kg, overweight women
(BMI 25–29.9) gain 7 to 11 kg, while obese women (BMI ≥ 30) gain 5 to 9 kg. Women were
then classed as gaining weight inadequately (below recommendations), adequately (within
recommendations) or excessively (above recommendations).
Body Attitude.
Body attitudes were assessed at T1 and T2 using the Ben-Tovim Walker Body
Attitudes Questionnaire (BAQ; Ben-Tovim & Walker, 1991). For the current study, four
subscales relevant to pregnancy were included; salience of weight and shape (salience),
attractiveness, strength and fitness, and feeling fat (Skouteris, 2011). The disparagement and
lower body fatness subscales are not deemed relevant during pregnancy and were not
included in this study. Participants were asked to rate each item on a Likert scale from 1
(‘strongly disagree’) to 5 (‘strongly agree’) based on how they had felt over the past month.
Negatively worded items (‘I hardly ever feel fat’) were reverse scored. Item scores were then
summed to create a total score for each subscale. The BAQ has satisfactory test-retest
reliability and validity in non-pregnant populations (Ben-Tovim & Walker, 1991) and good
internal consistency in pregnant populations (Duncombe et al. 2008). The 28-item BAQ in
the present study showed acceptable reliability at T1 (Cronbach’s α: salience = .79,
attractiveness = .67, strength and fitness = .76, feeling fat = .92), and T2 (Cronbach’s α:
salience = .80, attractiveness = .65, strength and fitness = .76, feeling fat = .93).
Statistical Analyses
Data were screened and cleaned prior to analyses. Missing data analyses were
performed and results reveal that Little’s Missing Completely at Random (MCAR; Little,
1988) test was not significant, X 2= 1672.31, df = 1626, P =.207, indicating that missing data
were MCAR. No variable had more than 5% missing data. Missing data were replaced using
5
Expectation Maximisation. Univariate outliers were replaced with a value one unit higher or
lower than the next valid unit. Two cases with multivariate outliers were deleted. As prepregnancy BMI, total GWG and BAQ salience subscale violated normality, bias-corrected
bootstrapping with 1000 bootstrap samples was used (Field, 2013).
Descriptive analyses were conducted on demographic variables. A moderation
analysis examined whether the relationship between body attitudes and GWG was moderated
by pre-pregnancy BMI. One model was conducted for each BAQ subscale at T1 and T2,
respectively. Each model was repeated, firstly as an unadjusted model, and secondly after
adjusting for age, annual family income, level of education, and parity (consistent with prior
research exploring body image and GWG; Hill et al., 2013). All analyses were run using a
dichotomous categorisation of pre-pregnancy BMI: underweight/normal weight vs.
overweight/obese. A conceptual illustration of the proposed model is depicted in Figure 1.
All analyses were conducted using IBM SPSS Statistics version 23. The PROCESS macro
(v2.16) was used to conduct the moderation analyses (model 1; Hayes, 2012). Variables were
mean centred, heteroscedasticity was controlled for and 1000 samples bias corrected,
accelerated bootstrapping was used.
FINDINGS
Participant Characteristics
Of the 734 pregnant women who expressed interest in the study, 474 (64.6%)
consented and completed a baseline questionnaire. Only participants who provided height,
pre-pregnancy weight, a final weight measurement taken at greater than or equal to 35 weeks’
gestation, and completed the BAQ at T1 and T2 were eligible for analysis, resulting in a final
sample of 280 women (59.1%). Participant characteristics are presented in Table 1. Women
were 16.81 weeks pregnant at T1 (standard deviation [SD] = 1.18, range 15-22), with a mean
age of 30.85 years (SD = 4.58, range 19-44). Participants had a relatively high socioeconomic background: 81.8% were born in Australia, 65.7% had completed an undergraduate
or postgraduate degree, and 38.2% had a combined family income in excess of
AUD$125,000. At time of the study, the average household income in Australia for a couple
with children under 5 years was $87,152 (Australian Bureau of Statistics, 2013). For 47.9%
of women, it was their first pregnancy. Women had a mean pre-pregnancy BMI of 25.36 (SD
= 5.61, range 16 - 43), 40.0% of women were classified as overweight or obese prior to
pregnancy and 42.5% exceeded the 2009 IOM recommendations for GWG (IOM, 2009).
Table 2 presents the means and standard deviations for pre-pregnancy BMI, GWG, and body
6
attitude subscales at T1 and T2, and bivariate correlations between continuous variables.
Women who were retained for analyses reported a higher annual family income (P = .004),
and were more likely to be born in Australia (P = .006) than women who were excluded;
there were no other statistical differences between women retained in the study and those
who were excluded.
Moderation at T1
Results of the moderation with T1 body attitudes are displayed in Table 3
(unadjusted) and Table 4 (adjusted). Findings did not differ between unadjusted and adjusted
analyses, therefore findings for unadjusted analyses are reported only in Table 3 and findings
for adjusted analyses are summarised in Table 4 and below.
Salience.
In the adjusted model, when controlling for age, family income, education, and parity,
10% of the variance in GWG was significantly explained by salience, pre-pregnancy BMI
and their interaction F(7,272) = 3.94, P < .001, R2 = .10. Lower pre-pregnancy BMI was
significantly associated with higher total GWG (b = -2.28, P < .001) and higher salience
scores were also associated with higher GWG (b = .27, P = .007). However, the relationship
between salience and GWG was not moderated by pre-pregnancy BMI (b = -.32, P = .084).
Attractiveness.
In the adjusted model, 10% of the variance in GWG was significantly explained by
attractiveness, pre-pregnancy BMI and their interaction F(7,272) = 3.30, P = .002, R2 = .10.
Lower pre-pregnancy BMI was significantly associated with higher total GWG (b = -2.18, P
= .003). Attractiveness was not a significant predictor of GWG (b = -.19, P = .115). The
relationship between attractiveness and GWG was not moderated by pre-pregnancy BMI (b =
.47, P = .050).
Feeling Fat.
In adjusted analyses, 12% of the variance in GWG was significantly explained by
feeling fat, pre-pregnancy BMI and their interaction F(7,272) = 3.93, P < .001, R2 = .12.
Lower pre-pregnancy BMI was significantly associated with higher total GWG (b = -1.96, P
= .004). Higher scores on the feeling fat subscale were associated significantly with higher
GWG (b = .07, P =.028). The relationship between feeling fat and GWG was moderated by
pre-pregnancy BMI (b = -.20, P = .002). Further exploration of conditional effects displayed
in Feeling fat was associated significantly with GWG for normal/underweight women (b =
.07, P = .029) and overweight/obese women (b = -.13, P = .023). That is, for women entering
pregnancy with an underweight/normal BMI, higher scores for feeling fat were associated
7
with higher GWG, while for women entering pregnancy with an overweight/obese BMI,
higher feeling fat scores were associated with lower GWG (Figure 2).
Strength and Fitness.
In adjusted analyses, 11% of the variance in GWG was explained by strength and
fitness, pre-pregnancy BMI and their interaction F(7,272) = 3.44, P = .002, R2 = .11. Lower
pre-pregnancy BMI was significantly associated with higher total GWG (b = -2.09, P = .003).
Strength and fitness did not predict GWG (b = -.11, P = .163). There was a significant
interaction effect indicating that pre-pregnancy BMI moderated the relationship between
strength and fitness and GWG (b = .36, P = .030). However, exploration of the conditional
effects showed that there was no moderation present when pre-pregnancy BMI was classified
as underweight/normal (b = -.11, P = .163) or overweight/obese (b = .24, P = .089),
indicating the interaction holds no clinical relevance.
Moderation at T2
Results of the moderation with body attitudes measured at T2 are displayed in Table 5
(unadjusted) and Table 6 (adjusted). Findings did not differ between unadjusted and adjusted
analyses, therefore findings for unadjusted analyses are reported only in Table 5 and findings
for adjusted analyses are summarised in Table 6 and below.
Salience.
In an adjusted model, when controlling for age, family income, education, and parity,
12% of the variance in GWG was significantly explained by salience, pre-pregnancy BMI
and their interaction F(7,272) = 4.13, P < .001, R2 = .12. Lower pre-pregnancy BMI was
associated significantly with higher total GWG (b = -2.24, P = .002). Higher scores on the
salience subscale were associated significantly with higher GWG (b = .31, P = .002). The
relationship between salience and GWG was moderated by pre-pregnancy BMI (b = -.54, P =
.020). Further exploration of conditional effects displayed in Figure 3 indicated that for
women entering pregnancy underweight/normal weight, high levels of salience were
associated significantly with higher GWG (b = .31, P = .002). This relationship did not hold
true for overweight/obese women (b = -.23, P = .274).
Attractiveness.
In adjusted analyses, 12% of the variance in GWG was significantly explained by
attractiveness, pre-pregnancy BMI and their interaction F(7,272) = 4.35, P < .001, R2 = .12.
Lower pre-pregnancy BMI was associated significantly with higher total GWG (b = -2.25, P
= .002). Lower feelings of attractiveness were associated significantly with higher GWG (b =
-.28, P = .009). Body mass index moderated the relationship between attractiveness and
8
GWG (b = .63, P = .004). Further exploration of conditional effects displayed in Figure 4
indicated that attractiveness was associated with GWG for normal/underweight women (b = .28, P = .009) but not overweight/obese women (b = .36, P = .065). Thus, for women
entering pregnancy with an underweight/normal weight BMI, low attractiveness scores were
associated with higher GWG.
Feeling Fat.
In adjusted analyses, 13% of the variance in GWG was significantly explained by
feeling fat, pre-pregnancy BMI and their interaction F(7,272) = 5.20, P < .001, R2 = .13.
Lower pre-pregnancy BMI (b =-2.33, P = .001) and higher scores of feeling fat (b = .13, P <
.001) were associated significantly with higher GWG. Pre-pregnancy BMI moderated the
relationship between feeling fat and GWG (b = -.21, P = .004). Further exploration of
conditional effects displayed in Figure 5 indicated that for women entering pregnancy with an
underweight/normal BMI, higher feeling fat scores were associated with higher GWG (b =
.13, P < .001). This relationship did not hold true for overweight/obese women (b = -.08, P =
.224).
Strength and Fitness.
In adjusted analyses, 12% of the variance in GWG was significantly explained by
strength and fitness, pre-pregnancy BMI and their interaction F(7,272) = 3.71, P < .001, R2 =
.12. Lower pre-pregnancy BMI (b = -2.16, P = .002) and lower strength and fitness scores (b
= -.15, P = .050) were associated with higher GWG. Pre-pregnancy BMI moderated the
relationship between strength and fitness and GWG (b = .50, P = .008). Exploration of
conditional effects displayed in Figure 6 indicated that strength and fitness was not associated
with GWG for normal/underweight women (b = -.15, P = .050), but for overweight/obese
women, high scores on the feeling fat subscale were associated with higher GWG (b = .35, P
= .043).
DISCUSSION
The aim of the present study was to explore the moderating role of pre-pregnancy
BMI on the relationship between maternal body attitudes in early-to-mid and late pregnancy
and GWG. To knowledge, only three other studies have explored pre-pregnancy BMI,
maternal body attitudes, and their relationship with GWG, and none explored this
relationship prospectively throughout pregnancy (Walker, 1998; Copper et al., 1995; Mehta
et al., 2011). All three studies found associations between GWG, pre-pregnancy BMI and
body image-related constructs such as maternal feelings towards antenatal weight gain, body
9
type preference, and discrepancy between current and ideal body. The current study extended
these findings by exploring the potential moderating effect of pre-pregnancy BMI on the
relationship between body image and GWG in both early-mid and late pregnancy.
In early-mid pregnancy (T1), the relationship between body attitudes and GWG was
moderated by pre-pregnancy BMI under one facet of the BAQ: feeling fat. When women
were classified as underweight/normal weight versus overweight/obese, feeling fat in earlymid pregnancy was associated with higher GWG only for women who began pregnancy
underweight/normal weight. For women who began pregnancy overweight/obese, feeling fat
in early-mid pregnancy was associated with lower GWG. A possible explanation for the
moderating effect of underweight/normal weight pre-pregnancy BMI on the relationship
between feeling fat in early-mid pregnancy and GWG is that women who gain a large amount
of weight in early pregnancy may experience feelings of fatness, and this early weight gain
(by 12 to 14 weeks gestation) is strongly predictive of total GWG (Overcash et al., 2015).
Given that overweight and obese women are more likely to experience less GWG overall
(Daemers, et al., 2013; de Jersey et al., 2012), it is possible that overweight and obese women
have not experienced a significant increase in their weight to the point that they report greater
feelings of fatness in early-mid pregnancy. Furthermore, they may not ‘feel fat’ due to their
current pregnant state not differing greatly from their usual shape and form. Despite the fact
that women tend to accept the pregnant body as a functional being, which can mitigate body
image concerns (Watson et al., 2015), it is conceivable that women entering pregnancy at an
underweight or normal weight BMI may find the associated change in body shape more
difficult to accept, particularly in early pregnancy where women may experience a thickening
around the middle without necessarily “looking pregnant”. Qualitative research supports this
hypothesis (Nash, 2012; Earle, 2003; Watson et al., 2015).
In contrast to the null findings in early-mid pregnancy for strength and fitness,
salience, and attractiveness, in late pregnancy, pre-pregnancy BMI moderated the association
between all four facets of body attitudes and GWG. For women who began pregnancy
underweight/normal weight, feeling fat and salience of weight and shape were associated
with higher GWG, and attractiveness was associated with lower GWG; these relationships
did not hold for overweight/obese women. As such, it can be proposed that body image
concerns are more salient in late pregnancy due to a greater change in body shape and weight,
and that women with an underweight or normal preconception BMI are more susceptible to
these three body image concerns in late pregnancy. However, strength and fitness was
associated with higher GWG for women who began pregnancy overweight/obese; there was
10
no association between strength and fitness and GWG for women who entered pregnancy
underweight/normal weight. We can speculate that being heavier (i.e., gaining more
gestational weight) leads to overweight/obese women feeling strong and fit because weight
gain is associated with growing a healthy baby – particular with societal norms such as eating
for two and the negative connotations linked with poor GWG (Kraschnewski & Chuang,
2014; Chuang et al., 2014). In underweight/normal weight women, this relationship may be
overshadowed by the salience of their body image concerns and dramatic changes in body
size, shape, and functionality during pregnancy (Watson et al., 2015; Earle, 2003).
The findings of this paper shed some light on the complex and oft-reported
contradictory nature of the impact of body image concerns on GWG (Kapadia et al., 2015;
Hill et al., 2013), highlighting that pre-pregnancy BMI moderates the relationship between
body attitudes and GWG under certain conditions. However, it is possible that other factors
are implicated in this relationship, particularly in early-mid pregnancy where the moderating
role of pre-pregnancy BMI was less consistent. For instance, Hill et al. (2016) reported that
depression, body image, self-efficacy and motivation were associated with excessive GWG.
Specifically, higher dissatisfaction with buttock size was associated with low levels of
readiness to consume a healthy diet, and the relationship between body image (specifically
buttocks dissatisfaction) and GWG was mediated by motivation (Hill et al., 2016). Similarly,
higher levels of depression and lower perceived social support are consistently associated
with excessive GWG (Hartley et al., 2015). Future research should consider psychosocial,
motivation and behaviour change factors when exploring body image concerns in pregnancy
in association with GWG.
Limitations
The authors acknowledge several limitations within the present study. Firstly, the
accuracy and objectivity of weight and height measurements have the potential to affect the
pre-pregnancy BMI and total GWG calculations used within the present study. All women
self-reported their pre-pregnancy weight and 61.4% of women self-reported their height.
However, pregnant woman are reasonably accurate in reporting their pre-pregnancy weight
(Herring et al., 2008). Furthermore, given the practical difficulties associated with recruiting
women prior to pregnancy and following them until they become pregnant, the use of selfreported weight to compute pre-pregnancy BMI is considered acceptable practice in GWG
research (IOM, 2009).
Secondly, the current study included a homogenous sample that consisted of highly
educated Australian women from a high socio-economic background. The relationship
11
between pre-pregnancy BMI and GWG may differ based on ethnicity (Bahadoer et al. 2015).
Maternal education is also reported to affect GWG, an interaction which is dependent on
ethnicity and socio-economic status (Huynh et al., 2014). We attempted to account for these
factors by controlling for annual family income and maternal education in analyses.
Thirdly, underweight and normal weight women were grouped together for the
categorical moderation analyses, which assumes that the relationship between body attitudes
and GWG is similar for underweight and normal weight women. The analyses were repeated
excluding the nine underweight women with no meaningful difference in findings. Hence, the
full sample was retained for analyses.
Finally, whilst prospective relationships (between body attitudes in early-mid and late
pregnancy and total GWG) were explored, it should be noted that causality cannot be
inferred. As such, it is possible that weight gained throughout the course of pregnancy and
therefore contributing to total GWG may impact on body attitudes during gestation. The
possibility that weight gain is the perpetuating factor in antenatal body image concerns
cannot be overlooked.
Implications and Conclusions
In conclusion, the results of our study suggest that for women with an underweight or normal
weight preconception BMI (who are therefore not typically at risk for high GWG), attention
to body image concerns should be a priority. Identifying and understanding modifiable risk
factors such as pre-pregnancy BMI, body attitudes and their inter-relationship is needed to
gain a comprehensive understanding of these multifaceted relationships. Such knowledge
may aid in the development and implementation of suitable screening tools to help healthcare
professionals accurately identify women who are at risk of excessive GWG, which may
facilitate healthy GWG and promote positive maternal and infant health outcomes. In
particular, identifying and addressing body image concerns earlier in pregnancy, where the
associations between body image and GWG are less significant, but where impact on future
body image concerns can be made, may be a useful opportunity with a potential impact on
overall GWG. Furthermore, careful monitoring of GWG throughout pregnancy may facilitate
women to maintain a positive body image.
Ethical Statement
Conflict of Interest
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The authors have no conflicts of interest to disclose.
Ethical Approval
Ethical approval was granted by the Human Research Ethics Committees of Deakin
University (36-2009) and Melbourne Health (2011.133).
Funding Sources
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Clinical Trial Registry and Registration Number
Not applicable.
Acknowledgements
Dr Briony Hill is funded by an Alfred Deakin Postdoctoral Research Fellowship.
References
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Figure Captions
Figure 1. Conceptual illustration of the moderating role of pre-pregnancy BMI in the
relationship between body attitudes and GWG. Adapted from Model Templates for Process
for SPSS and SAS © 2013-2015. Andrew F. Hayes and The Guilford Press. (Model 1).
Figure 2. Graphical representation of the relationship between Feeling Fat at T1 and GWG,
when pre-pregnancy BMI is categorised as underweight/normal (BMI < 25) and
overweight/obese (BMI ≥ 25; adjusted for age, family income, education and parity).
Figure 3. Graphical representation of the relationship between Salience at T2 and GWG,
when pre-pregnancy BMI is categorised as underweight/normal (BMI < 25) and
overweight/obese (BMI ≥ 25; adjusted for age, family income, education and parity).
Figure 4. Graphical representation of the relationship between Attractiveness at T2 and
GWG, when pre-pregnancy BMI is categorised as underweight/normal (BMI < 25) and
overweight/obese (BMI ≥ 25; adjusted for age, family income, education and parity).
17
Figure 5. Graphical representation of the relationship between Feeling Fat at T2 and GWG,
when pre-pregnancy BMI is categorised as underweight/normal (BMI < 25) and
overweight/obese (BMI ≥ 25; adjusted for age, family income, education and parity).
Figure 6. Graphical representation of the relationship between Strength and Fitness at T2 and
GWG, when pre-pregnancy BMI is categorised as underweight/normal (BMI < 25) and
overweight/obese (BMI ≥ 25; adjusted for age, family income, education and parity).
Table 1. Participant Characteristics
Demographic
Value
Weeks gestation at T1, M (SD)
16.81 (1.18)
Weeks gestation at T2, M (SD)
32.65 (0.91)
Weeks gestation at T3, M (SD)
37.15 (1.55)
Age, years, M (SD)
30.85 (4.58)
Education Level, n (%)
Year 12 or below
32 (11.4)
Certificate or Diploma
78 (22.9)
Undergraduate or
170 (65.7)
Postgraduate Degree
Income, n (%)
Under AUD$45,000
19 (6.8)
AUD$45,001-$85,000
66 (23.6)
AUD$85,001, $125,000
88 (31.4)
Above AUD$125,000
107 (38.2)
Parity, n (%)
Primiparous
134 (47.9)
Multiparous
146 (52.1)
Birth Location, n (%)
18
Australia
229 (81.8)
New Zealand
10 (3.6)
United Kingdom/Europe
20 (7.1)
United States
6 (2.1)
Asia
13 (4.6)
Middle East
1 (0.4)
Africa
1 (0.4)
Pre-pregnancy BMI, kg/m2, M (SD)
25.36 (5.61)
Pre-pregnancy BMI Category, n (%)
Underweight (< 18.5)
9 (3.2)
Normal weight (18.5-24.9)
159 (56.8)
Overweight (25.0 – 29.0)
66 (23.6)
Obese (
46 (16.4)
30)
13.37 (5.41)
GWG, kg, M (SD)
GWG category,a n (%)
Inadequate
60 (21.4)
Adequate
101 (36.1)
Excessive
119 (42.5)
Abbreviations: BMI, body mass index; GWG, gestational weight gain; M, mean; SD,
standard deviation; T1, time 1; T2, time 2; T3, time 3.
a
categorised according to the 2009 IOM recommendations.2
Table 2. Means, SD and Ranges of Pre-pregnancy BMI, GWG and the 4 BAQ subscales at T1
and T2 with Bivariate Correlations
Measu
1
2
3
4
5
6
7
8
9
1
M
SD
Ran
19
res
1. BMI
0
1
(kg/m2
ge
25.
5.6
16 –
36
1
43
13.
5.4
-4 -
37
1
26
16.
3.1
8-
56
0
23
31.
10.
12 -
76
57
56
18.
4.3
8–
36
2
29
11.
3.8
5–
41
2
24
16.
3.0
7-
49
9
25
29.
10.
12 -
59
29
55
)
2.
GWG
(kg)
3. ATT
(T1)
-
1
.398
**
-
.04
.213
5
1
**
4. FAT
(T1)
5. STR
(T1)
.368
-
-
**
.08
.454
8
**
-
.06
.302
-
.227
5
**
.292
**
6. SAL
(T1)
1
**
.226
.02
-
.757
-
**
9
.309
**
.239
**
7. ATT
(T2)
8. FAT
(T2)
1
1
**
-
-
.662
-
.289
-
.157
.01
**
.448
**
.349
**
2
.191
.07
-
.635
-
.528
-
**
4
.378
**
.276
**
.594
**
**
1
**
1
**
20
9. STR
(T2)
-
.06
.347
-
.648
-
.175
0
**
.328
**
.210
.360
**
**
**
10.
.056
SAL
**
.417
-
1
.05
-
.536
-
.545
-
.781
-
9
.269
**
.272
**
.479
**
.272
(T2)
**
**
**
1
17.
4.0
8-
80
1
28
11.
3.4
5-
09
1
22
**
Abbreviations: ATT, BAQ attractiveness; BAQ, Ben-Tovim Walker Body Attitudes
Questionnaire; BMI, body mass index; FAT, BAQ feeling fat; GWG, gestational weight gain;
M, mean; SAL, BAQ salience of weight and shape; SD, standard deviation; STR, BAQ strength
and fitness; T1, time 1; T2, time 2.
*Correlation is significant at .05.
**Correlation is significant at .01.
Table 3. Moderated Pathways for Body Attitudes at T1 with Pre-Pregnancy BMI categorised
as underweight/normal vs. overweight/obese (unadjusted)
95% CI
Model
b
SE
t
P
Lower Upper
.25
.09
2.67
.008
.07
.43
BMI  GWG
-2.85
.67
-4.26
< .001
-4.17
-1.54
Salience × BMI 
-.28
.18
-1.56
.119
-.63
.07
.25
.09
2.67
.008
.07
.43
-.03
.15
-
.840
-.33
.27
Salience
Pathway
Salience  GWG
GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
.20
21
Attractiveness
Pathway
Attractiveness 
-.19
.12
-1.57
.118
-.42
.05
BMI  GWG
-2.66
.69
-3.87
< .001
-4.01
-1.30
.47
.24
1.98
.048
.00
.94
-.19
.12
-1.57
.118
-.42
.05
.28
.21
1.38
.169
-.12
.69
Feeling Fat
.07
.03
2.18
.030
.01
.14
BMI  GWG
-2.46
.65
-3.78
< .001
-3.74
-1.18
Feeling Fat × BMI
-.20
.07
-2.94
.004
-.33
-.06
.07
.03
2.18
.030
.01
.14
-.12
.06
-2.14
.033
-.24
-.01
GWG
Attractiveness ×
BMI  GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Feeling Fat
Pathway
GWG
 GWG
Conditional Effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25
Strength & Fitness
22
Pathway
Strength & Fitness
-.12
.08
-1.56
.120
-.28
.03
-2.59
.67
-3.87
< .001
-3.90
-1.27
.36
.16
2.25
.025
.05
.68
-.12
.08
-1.56
.120
-.28
.03
.24
.14
1.71
.089
-.04
.52
 GWG
BMI  GWG
Strength & Fitness
× BMI  GWG
Conditional Effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Abbreviations: b, unstandardized regression coefficient; BMI, body mass index; CI,
confidence interval; GWG, gestational weight gain; SE, standard error; T1, time 1.
Table 4. Moderated Pathways for Body Attitudes at T1 with Pre-Pregnancy BMI categorised
as underweight/normal vs. overweight/obese (adjusted)
95% CI
Model
b
SE
t
P
Lower Upper
.27
.10
2.73
.007
.07
.46
BMI  GWG
-2.28
.68
-3.34
< .001
-3.63
-.94
Salience × BMI 
-.32
.18
-1.73
.084
-.68
.04
Salience
Pathway
Salience  GWG
GWG
Conditional effects
23
Underweight/Norm
.27
.10
2.73
.007
.07
.46
-.05
.15
-
.739
-.35
.25
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
.33
Covariates
Age
-.20
.08
-2.42
.016
-.37
-.04
Income
.28
.19
1.45
.149
-.10
.66
Education
-.06
.21
-.30
.765
-.49
.36
Parity
.82
.66
1.23
.219
-.49
2.12
Attractiveness 
-.19
.12
-1.58
.115
-.43
.05
BMI  GWG
-2.18
.72
-3.04
.003
-3.59
-.77
.47
.24
1.97
.050
.01
.93
-.19
.12
-1.58
.115
-.43
.05
.28
.20
1.35
.177
-.13
.68
Age
-.19
.08
-2.33
.021
-.36
-.03
Income
.21
.20
1.05
.295
-.18
.60
Education
-.08
.22
-.35
.725
-.50
.35
Attractiveness
Pathway
GWG
Attractiveness ×
BMI  GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
24
Parity
.74
.69
1.08
.281
-.61
2.09
Feeling Fat
.07
.03
2.21
.028
.01
.14
BMI  GWG
-1.96
.68
-2.89
.004
-3.30
-.63
Feeling Fat × BMI
-.20
.07
-3.09
.002
-.33
-.07
.07
.03
2.21
.029
.01
.14
-.13
.06
-2.28
.023
-.24
-.02
Age
-.20
.08
-2.38
.018
-.36
-.03
Income
.22
.19
1.15
.250
-.16
.60
Education
-.15
.21
-.69
.493
-.57
.28
Parity
.84
.67
1.25
.212
-.48
2.15
Strength & Fitness
-.11
.08
-1.40
.163
-.27
.05
BMI  GWG
-2.09
.71
-2.96
.003
-3.48
-.70
.36
.16
2.19
.030
.04
.68
Feeling Fat
Pathway
GWG
 GWG
Conditional Effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
Strength & Fitness
Pathway
 GWG
Strength & Fitness
× BMI  GWG
25
Conditional Effects
Underweight/Norm
-.11
.08
-1.40
.163
-.27
.05
.24
.14
1.71
.089
-.04
.53
Age
-.19
.08
-2.24
.026
-.35
-.02
Income
.23
.20
1.16
.249
-.16
.63
Education
-.11
.22
-.51
.612
-.55
.32
Parity
.83
.68
1.22
.224
-.51
2.16
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
Abbreviations: b, unstandardized regression coefficient; BMI, body mass index; CI,
confidence interval; GWG, gestational weight gain; SE, standard error; T1, time 1.
Table 5. Moderated Pathways for Body Attitudes at T2 with Pre-Pregnancy BMI categorised
as underweight/normal vs. overweight/obese (unadjusted)
95% CI
Model
b
SE
t
P
Lower Upper
.32
.10
3.09
.002
.12
.52
BMI  GWG
-2.73
.69
-3.96
< .001
-4.09
-1.37
Salience × BMI 
-.55
.24
-2.28
.024
-1.03
-.07
Salience
Pathway
Salience  GWG
GWG
Conditional effects
26
Underweight/Nor
.32
.10
3.09
.002
.12
.52
-.23
.22
-
.287
-.67
.20
mal (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
1.07
Attractiveness
Pathway
Attractiveness 
-.32
.11
-3.02
.003
-.52
.11
BMI  GWG
-2.70
.68
-3.99
< .001
-4.04
-1.37
.65
.22
2.98
.003
.22
1.08
-.32
.11
-3.02
.003
-.52
-.11
.34
.19
1.75
.082
-.04
.71
Feeling Fat
.14
.03
4.32
< .001
.08
.20
BMI  GWG
-2.76
.67
-4.09
< .001
-4.09
-1.43
Feeling Fat × BMI
-.21
.07
-2.91
.004
-.36
.07
.14
.03
4.32
< .001
.08
.20
GWG
Attractiveness ×
BMI  GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Feeling Fat
Pathway
GWG
 GWG
Conditional Effects
Underweight/Norm
27
al (BMI ≤ 24.9)
Overweight/Obese
-.07
.07
-1.12
.265
-.20
.06
-.15
.08
-1.94
.054
-.30
.00
-2.59
.66
-3.93
< .001
-3.89
-1.29
.49
.19
2.65
.009
.13
.86
-.15
.08
-1.94
.054
-.30
.00
.34
.17
2.03
.044
.01
.68
(BMI ≥ 25
Strength & Fitness
Pathway
Strength & Fitness
 GWG
BMI  GWG
Strength & Fitness
× BMI  GWG
Conditional Effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Abbreviations: b, unstandardized regression coefficient; BMI, body mass index; CI,
confidence interval; GWG, gestational weight gain; SE, standard error; T2, time 2.
Table 6. Moderated Pathways for Body Attitudes at T2 with Pre-Pregnancy BMI categorised
as underweight/normal vs. overweight/obese (adjusted)
95% CI
Model
b
SE
t
P
Lower Upper
.31
.10
3.12
.002
.12
.51
-2.24
.71
-3.16
.002
-3.63
-.84
Salience
Pathway
Salience  GWG
BMI  GWG
28
Salience × BMI 
-.54
.23
-2.35
.020
-1.00
-.09
.31
.10
3.12
.002
.12
.51
-.23
.21
-
.274
-.64
.18
GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
1.10
Covariates
Age
-.19
.08
-2.32
.021
-.35
-.03
Income
.24
.19
1.24
.215
-.14
.61
Education
-.08
.22
-.39
.696
-.51
.34
Parity
.78
.66
1.19
.236
-.51
2.08
Attractiveness 
-.28
.10
-2.63
.009
-.48
-.07
BMI  GWG
-2.25
.71
-3.18
.002
-3.63
-.86
.63
.22
2.90
.004
.20
1.06
-.28
.10
-2.63
.009
-.48
-.07
.36
.19
1.85
.065
-.02
.74
Attractiveness
Pathway
GWG
Attractiveness ×
BMI  GWG
Conditional effects
Underweight/Norm
al (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
29
Age
-.17
.08
-2.08
.038
-.34
-.01
Income
.22
.20
1.13
.260
-.17
.61
Education
-.12
.22
-.58
.562
-.55
.30
Parity
.92
.67
1.38
.168
-.39
2.24
Feeling Fat
.13
.03
4.13
< .001
.07
.19
BMI  GWG
-2.33
.70
-3.34
.001
-3.70
.96
Feeling Fat × BMI
-.21
.07
-2.91
.004
-.35
-.07
.13
.03
4.13
< .001
.07
.19
-.08
.07
-1.22
.224
-.21
.05
Age
-.17
.08
-2.13
.034
-.33
-.01
Income
.19
.19
1.01
.316
-.18
.56
Education
-.10
.22
-.47
.639
-.53
.33
Parity
.80
.65
1.22
.225
-.49
2.09
-.15
.08
-1.98
.050
-.30
.00
Feeling Fat
Pathway
GWG
 GWG
Conditional Effects
Underweight/Nor
mal (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
Strength & Fitness
Pathway
Strength & Fitness
 GWG
30
BMI  GWG
-2.16
.70
-3.08
.002
-3.54
-.78
.50
.19
2.67
.008
.131
.86
-.15
.08
-1.98
.050
-.30
.00
.35
.17
2.04
.043
.01
.68
Age
-.18
.08
-2.23
.027
-.34
-.02
Income
.20
.20
1.00
.317
-.19
.59
Education
-.13
.22
-.59
.554
-.57
.30
Parity
1.00
.67
1.49
.137
-.32
2.32
Strength & Fitness
× BMI  GWG
Conditional Effects
Underweight/Nor
mal (BMI ≤ 24.9)
Overweight/Obese
(BMI ≥ 25)
Covariates
Abbreviations: b, unstandardized regression coefficient; BMI, body mass index; CI,
confidence interval; GWG, gestational weight gain; SE, standard error; T2, time 2.
Highlights

Antenatal body attitudes are associated with gestational weight gain (GWG).

Body attitudes may differ based on pre-pregnancy BMI and gestational age.

Unhealthy GWG may be prevented through early assessment of antenatal body
attitudes
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