Lifestyle Intervention in Preparation for Pregnancy (LIPP)
Phase: NA
Conditions: Obesity, Lifestyle-related Condition, Macrosomia, Fetal
Sponsor: Tufts Medical Center

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
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STUDY TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
 
STUDY SPONSOR: National Institutes of Health 
 
PRINCIPAL INVESTIGATOR  
Patrick M. Catalano, MD  
Mother Infant Research Institute  
617-636-1468 
pcatalano@tuftsmedicalcenter.org 
 
Table of Contents – Click on the links below to go directly to the applicable section 
 
1. 
Study Schema Figure 7 in LIPP grant ............................................................................................................ 2 
2. Introduction ............................................................................................................................................................ 2 
2.1 
Background and Rationale ......................................................................................................................... 2 
2.2 
Risks to Subjects ........................................................................................................................................ 8 
2.3 
Potential Benefits to Subjects ................................................................................................................... 11 
2.4 
Alternatives .............................................................................................................................................. 12 
3 
Objectives ..................................................................................................................................................... 12 
4 
Enrollment and Withdrawal ......................................................................................................................... 14 
4.1 
Inclusion Criteria ...................................................................................................................................... 14 
4.2 
Exclusion Criteria ..................................................................................................................................... 15 
4.3 
Withdrawal of Subjects ............................................................................................................................ 15 
4.4 
Recruitment and Retention ....................................................................................................................... 15 
4.4.1 
Local Recruitment Methods ............................................................................................................. 15 
4.4.2 
Study-Wide Recruitment Methods ................................................................................................... 17 
4.4.3 
Payment ............................................................................................................................................ 17 
4.4.4 
Reimbursement................................................................................................................................. 18 
5 
Study Design ................................................................................................................................................ 19 
5.1 
Study Timelines........................................................................................................................................ 19 
5.2 
Procedures ................................................................................................................................................ 25 
5.3 
Evaluations ............................................................................................................................................... 26 
5.4 
Collection and Storage of Human Biological Specimens (Tissue Banking) ........................................... 27 
6 
Ethics and Protection of Human Subjects .................................................................................................... 27 
6.1 
Informed Consent Process ........................................................................................................................ 27 
6.2 
Waiver or Alteration of Consent Process ................................................................................................. 28 
6.3 
International Research .............................................................................................................................. 28 
6.4 
Confidentiality .......................................................................................................................................... 28 
6.5 
Provisions to Protect the Privacy Interests of Subjects ............................................................................ 29 
6.6 
Provisions to Monitor the Study to Ensure the Safety of Subjects .......................................................... 30 
6.7 
Compensation for Research-Related Injury ............................................................................................. 31 
6.8 
Economic Burden to Subjects .................................................................................................................. 31 
6.10 Vulnerable Populations ................................................................................................................................ 31 
7 
Adverse Event Monitoring ........................................................................................................................... 34 
7.1 
Definitions ................................................................................................................................................ 34 
7.2 
Reporting Procedures ............................................................................................................................... 37 
7.3 
Reportable New Information .................................................................................................................... 38 
Reportable new information will be reported to the IRB per the Tufts Health Sciences IRB’s Reportable New 
Information Policy.................................................................................................................................................... 38 
8 
Statistical Considerations ............................................................................................................................. 38 
8.1 
Study Endpoints ....................................................................................................................................... 38 
8.2 
Statistical Analysis ................................................................................................................................... 38 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
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8.3 
Number of Subjects .................................................................................................................................. 39 
8.4 
Data Management .................................................................................................................................... 39 
8.5 
Randomization ......................................................................................................................................... 40 
9 
Drugs or Devices .......................................................................................................................................... 40 
10 
Study Administration ................................................................................................................................... 41 
10.1 
Setting....................................................................................................................................................... 41 
10.2 
Registration .............................................................................................................................................. 41 
10.3 
Resources Available ................................................................................................................................. 41 
10.4 
IRB Review .............................................................................................................................................. 43 
10.5 
Multi-Site Research .................................................................................................................................. 43 
10.6 
Community-Based Participatory Research .............................................................................................. 45 
10.7 
Sharing Results with Subjects .................................................................................................................. 45 
11 
Addendums................................................................................................................................................... 45 
11.1 
Site Specific Changes: Pennington Biomedical Research Center ............................................................ 45 
11.2 
Opt-In Ancillary Studies .......................................................................................................................... 48 
11.2.1 Breast Milk Collection  ................................................................................................................................. 48 
12 
References ........................................................................................................................................ 49 
 
1. Study Schema Figure 7 in LIPP grant 
 
 
 
 
Please note that in accordance with Tufts IRB, the format of this protocol is Boston area specific with 
addendums for each site detailing local research activities. 
 
2. Introduction 
2.1 Background and Rationale 
 
Lifestyle interventions during pregnancy: are they successful? There have been numerous randomized 
clinical trials (RCT) examining lifestyle interventions for obese women during pregnancy. These RCTs had 
primary outcomes that included avoiding excessive gestational weight gain (GWG), and decreasing 
adverse perinatal outcomes, such as gestational diabetes (GDM), preeclampsia and large for 
gestational age (LGA) neonates (17,18,19,20,21). A recent Danish RCT on lifestyle intervention 
Lifestyle intervention program. *HNRCA or CTRC visit for body composition, OGTT, inflammatory 
markers; + post-partum: newborn body composition, cord blood, placenta at TMC. 

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consisting of dietary guidance, free fitness club membership, and personal coaching initiated between 10-14 
weeks’ gestation (18) reported that although there was a decrease in GWG in the intervention group (7.0 
vs. 8.6 kg, p=0.01), paradoxically infants in the lifestyle intervention group had higher birth weight (3,742 
vs. 3,593 g, p=0.04) compared to controls. Other recent RCTs (UPBEAT and the Norwegian Fit for 
Delivery Trial) suggest that behavioral lifestyle interventions do not prevent GDM or reduce the incidence 
of LGA babies despite reducing maternal dietary glycemic load, GWG, and maternal skinfold measures, and 
increasing physical activity (22,23).  At least five meta-analyses published in the past four years, all concluded 
that lifestyle interventions initiated during pregnancy, while having some success in reducing excessive 
GWG, had minimal positive effects on adverse pregnancy outcomes including decreasing fetal overgrowth 
(24, 25, 26, 27, 28). Although some advocate weight loss in obese women during pregnancy, these 
recommendations are based on extrapolation of epidemiological data (29, 30, 31). Investigators in the 
UPBEAT trial noted that increasing the intensity and duration of the lifestyle intervention was likely to 
be impractical for most obese women (22) Further, we reported an increased risk of small for gestational 
age (SGA) neonates and decreased lean body mass (head circumference and length) in neonates of 
overweight/obese women with inadequate GWG (32). 
 
Post-delivery weight loss: is it possible and safe, and what is the effect on subsequent pregnancies? 
Publications related to postpartum weight loss have been primarily retrospective cohort studies reporting 
that ~10-20% of overweight/obese women had a decrease in weight between pregnancies (33, 34, 35, 36).  
The interval between pregnancies was 12 months in 30% and 24-36 months in 40-57% of subjects (34, 
37). Inter-pregnancy weight loss in overweight/obese women was associated with a decreased risk of GDM 
or preeclampsia (35, 36, 38, 39) in a subsequent pregnancy. Three studies reported a decreased incidence 
of LGA in overweight/obese women who had an inter-pregnancy decrease of as little as 1-2 BMI units 
(34, 37, 38). The inter-pregnancy decrease in weight was not associated with an increased risk of SGA 
infants (34). 
 
Four RCTs reported that postpartum lifestyle intervention was effective in facilitating weight loss compared 
to a control group. Lovelady reported weight loss of 0.5 kg/week between 4-14 weeks postpartum in 
overweight women who were breastfeeding. Weight loss did not affect infant growth (40). Similarly, 
Colleran reported that a 16- week diet and exercise intervention resulted in a 5.8 kg weight loss in 
overweight and obese lactating women without adverse effects on infant growth (41). Stendall-Hollis 
showed that overweight women, most of whom were exclusively breastfeeding, lost 3-4% of body weight 
and significantly decreased biomarkers of inflammation (42). O’Toole reported a mean 5.6 kg weight loss 
at 12 weeks; weight loss was primarily fat mass (43). A recent meta-analysis of 11 studies with 769 subjects 
reported a significant mean -2.57 kg (95% CI -3.6 to -1.5) weight loss in the intervention group. In a 
subgroup analysis, the most effective interventions were those with objective goals; use of heart rate 
monitors, pedometers, and exercise combined with intensive dietary intervention, and these interventions 
produced a -4.1 kg (95% CI -5.2 to -3.5) weight loss (44). Therefore, supervised intensive lifestyle 
intervention in overweight and obese postpartum women is feasible, efficacious, and safe, in lactating 
women. The concept that lifestyle intervention before pregnancy is necessary to improve placental function 
and fetal development is strongly supported by scientific and clinical observations, and is gaining traction as 
a viable paradigm to improve perinatal metabolic outcomes (45). 
 
Summary: Lifestyle intervention initiated during pregnancy helps reduce excessive GWG; however, it 
has not been successful in reducing fetal overgrowth. Based on our research we conclude that lifestyle 
intervention needs to be initiated prior to conception. Just as women with pre-existing diabetes need to 
normalize glucose before pregnancy to decrease the risk of congenital anomalies, obese women must improve 
metabolic conditioning before pregnancy to decrease complications of fetal overgrowth during pregnancy 
(46).  We reported an increased expression of lipogenic and inflammatory genes in placenta of obese women 
in the early first trimester, before any phenotypic change becomes apparent (47). The intervention proposed 
in this application includes an established exercise, diet and behavioral modification program that have 
proven, through prospective RCTs, to be successful in improving overall metabolic function by decreasing 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
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body weight/adiposity in obese non-pregnant individuals (48). Collectively these data provide evidence 
that lifestyle intervention initiated prior to conception will have short- and long-term benefit for the mother 
and her baby. 
Relevant Preliminary Data by PI and Co-Is 
Maternal obesity/hyperinsulinemia affects placental growth and gene expression in early 
pregnancy. Lean and obese women were recruited prior to a planned pregnancy and underwent 
longitudinal clamps, and intravenous glucose tolerance tests (IVGTT). There was a 3.7-fold 
increase in insulin response to the IVGTT in obese vs. lean women. The increase in insulin 
response in early pregnancy correlated with placental growth and fetal adiposity at term (r=0.64, 
p=0.0001) (59). 
Increased insulin response in obese women results in altered expression of placental lipid 
metabolism genes. We recruited 48 lean and obese women scheduled for elective first trimester 
termination. After metabolic evaluations placentas were obtained for molecular analysis. At 9 
weeks gestation, insulin resistance, leptin, IL-6 and C-reactive protein (CRP) were increased in 
obese vs. lean subjects. CRP correlated with maternal BMI and insulin sensitivity. Using global 
gene profiling analysis of trophoblast cells, we identified 355 genes differentially regulated in 
obese vs. normal weight women. Pathway analysis revealed a significant decrease in the 
expression of genes regulating β- oxidation, cholesterol and steroid synthesis. 
Since β-oxidation and initial steps of steroid biosynthesis occur in mitochondria, these data 
suggest impairment of trophoblast mitochondrial function during early pregnancy in insulin 
resistant obese women. We further postulate that in obese women, hyperinsulinemia and/or 
defective insulin action alter placental gene expression. We cultured first trimester human 
trophoblast cells, with and without insulin (100 nM), to investigate insulin effects. In trophoblasts 
derived from lean women, 2,875 genes were differentially regulated by insulin, whereas only 87 
genes were regulated in obese women. These data suggest that the effect of insulin on trophoblast 
cells is less robust in obese women (60). By improving maternal insulin sensitivity and 
decreasing β-cell response through lifestyle intervention before conception, the decrease in 
insulin response will affect placental programming of genes related to lipid metabolism and 
mitochondrial function. This will result in decreased placental lipid accumulation and nutrient 
availability to limit neonatal adiposity. Thus, interventions aimed at improving maternal 
metabolic function should begin before initiation of molecular changes. These data are highly 
supportive of our hypothesis that when lifestyle intervention is initiated after placental gene 
expression has been programmed the effects are not reversed. 
 
Potential subjects for recruitment: We have a track record of successfully recruiting and 
retaining women prior to a planned pregnancy for longitudinal metabolic studies 
(15,50,51,52,53,54,55,56,57,58).  While the number of subjects in the individual protocols were 
in the range of 20-25, there were multiple protocols over 20 years that were funded by 6 different 
R01 or Program Project mechanisms, (total n > 200). Note; these longitudinal studies involved 
clamps, muscle and fat biopsies as well as estimates of energy expenditure and body composition.   
In this protocol we will initiate recruitment in our postpartum unit after the index or 
subsequent delivery. Using our perinatal database of all obese women (for the purposes of this 
proposal defined as a BMI 25-35 kg/m2 for the general population, and 23-32.5 kg/m2 for Asian 
populations as defined by the WHO guidelines, 95), we estimated the time from delivery of their 
first infant to their next pregnancy. Approximately 1,665 women (32%) became pregnant within 
18 months and 2328 (45%) within 24 months of their first delivery. We anticipate the time 
interval will be considerably less if we recruit women planning to conceive, who do not have a 
history of infertility and because the number of unplanned pregnancies is decreasing (3). Further, 
we have a record of excellent success with retention in previous postpartum women (pre-
pregnancy relative to the LIPP). We also have follow-up of women and their children at 4, 8 and 
12 months postpartum for body composition studies (61). To date, we have recruited over 250 

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women (>85% of eligible subjects) and their offspring from the Hyperglycemia and Adverse 
Pregnancy Outcome (HAPO) follow-up study 8-12 years after delivery. 
 
Inter-pregnancy weight loss or gain: In a sub-cohort of our population (n=126), we examined 
the effect of maternal weight change from the first to second pregnancy. Of the 126 women, 20 
(16%) lost weight and 106 (84%) gained weight between pregnancies. In the subsequent 
pregnancy, women who lost weight delivered infants with a minimal change in mean birth 
weight, whereas women with an increase in inter-pregnancy weight delivered infants that were on 
average 107g heavier at birth.  These data are consistent with a report (34) from more than 10,000 
births in obese women. Inter- pregnancy weight loss was associated with a lower risk of LGA 
infants (OR: 0.61; 0.52-0.73), whereas weight gain was associated with an increased risk of LGA. 
We examined body composition of neonates in successive pregnancies where mothers (BMI-25-
35 kg/m2) had either gained (n=10) or lost weight (n=5). Women with an inter-pregnancy weight 
loss had a mean decrease in birth weight of 349 g (183 g fat and 40 g lean mass). In those with an 
inter-pregnancy weight gain, there was a mean 63 g increase in birth weight, which was 
comprised of 33 g body fat and 11 g lean mass. There was a net 216 g difference in fat, but only a 
51g difference in lean mass between women who lost and gained weight. The effect of weight 
loss between pregnancies was primarily due to a change in neonatal fat. We have also reported 
that neonatal fat mass is significantly correlated with childhood adiposity (15). 
 
Importance of weight loss for restoration of insulin sensitivity postpartum: We used 
euglycemic clamps and molecular approaches to identify mechanisms that regulate insulin 
sensitivity in obese women during late pregnancy and one year postpartum (62). Women who did 
not lose weight within one year after delivery did not reverse pregnancy-related insulin resistance, 
and fasting glucose and plasma TNF-α remained elevated.  Further, in the absence of weight loss, 
skeletal muscle TNF-α gene expression and 312Serine-IRS-1 phosphorylation did not recover to 
pre-pregnancy levels. These data suggest that women who fail to lose weight postpartum are at 
greater risk of increased insulin resistance in a subsequent pregnancy. The progressive insulin 
resistance may accelerate the decline in β-cell function and development of type 2 diabetes. In 
contrast, women who were followed for one year postpartum, but lost significant weight (63), 
experienced normalization of fasting glucose and insulin, insulin sensitivity, and insulin signaling 
in skeletal muscle. These data highlight the importance of postpartum weight loss to the 
metabolic health of the mother. 
 
Lifestyle intervention induces weight loss and improved metabolic function: exercise and 
caloric restriction in obesity - a randomized clinical trial. We conducted a prospective study in 
24 obese (BMI: 34.3 ± 5.2 kg/m2) adults randomized to exercise alone, or exercise combined 
with moderate caloric restriction (-500 kcal/d (48). Both interventions improved insulin 
sensitivity (p<0.001), and cardiovascular risk factors (systolic/diastolic blood pressure, waist 
circumference, glucose and triglycerides; p<0.05).  Total abdominal, subcutaneous, and visceral 
fat, aerobic capacity, total and LDL cholesterol also improved. These data support the efficacy of 
our weight loss intervention in reducing body weight and improving insulin sensitivity in obese 
individuals. 
 
Mechanisms related to pancreatic β-cell function: effects of lifestyle induced weight loss on 
β-cell function and the GLP-1 response to glucose. We examined the effect of exercise/diet 
induced weight loss on β-cell function, insulin secretion, and the incretin (GLP-1 and GIP) 
response to nutrient stimulation as part of NIH funded obesity and insulin resistance studies.  In 
obese adults, a low glycemic diet combined with exercise induced weight-loss and reduced 
postprandial hyperinsulinemia (48, 64, 65). In contrast, a high glycemic diet impaired pancreatic 
β-cell and intestinal K-cell function, despite weight loss. Our research nutritionist will counsel 
participants to eat a Mediterranean-style diet during the lifestyle intervention.  Counseling will be 

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consistent with the subject’s metabolic status, food availability, and cultural needs. We have also 
shown (data in review) that lifestyle-induced weight loss decreases the GLP-1 response to 
glucose. There are no published data on the effects of lifestyle-induced   weight   loss   on   GLP-
1   responses   to   nutrient   stimulation   in pregnancy. The current application will address this 
knowledge gap. 
 
Preliminary Data  
 
Placental lipid metabolism pathways are altered in obese women at term. We measured fatty acid 
metabolism gene profiles in placentas of 40 lean and 40 obese women as part of our NIH-funded 
placental lipid studies. Carnitine palmitoyltransferase (CPT) 1B, the rate-limiting enzyme in the 
mitochondrial fatty acid oxidation pathway, is lower in term placentas of obese women, while key 
genes in fatty acid esterification and accumulation (acetylCoA carboxylase (ACC), steroyl CoA-
desaturase (SCD) 1, and fatty acid binding protein 4 (FABP4) are higher. Consistent with these gene 
pathways, 3H-palmitate esterification was higher in primary trophoblasts isolated from 11 obese 
women compared to 5 lean women. These data provide a potential mechanism for our finding that 
placental lipid content is 17% higher in obese (N=15) vs.   lean (N=14) women. In a RCT (PMC), we 
found that overweight and obese women randomized to omega-3 fatty acid supplementation starting in 
the early 2nd trimester had lower expression of lipid esterification genes (i.e. DGAT1 by 22%, 
adipophilin (PLIN2) by 33%) and lower placenta esterified fatty acid content compared to placebo 
(32±8 vs. 43±12 nmol/mg), but fatty acid oxidation genes and neonatal fat mass were not improved 
(66). In fact, birthweight increased 25% with omega-3 supplementation.  Further, omega-3 did not alter 
3H-palmitate oxidation in vitro, but decreased 3H-palmitate esterification ~50% in trophoblasts isolated 
from obese women (N=11). These data suggest that: 
1) Intervention initiated during pregnancy in obese women does not improve placental mitochondrial 
function or neonatal adiposity, and 2) lowering lipid esterification and storage in placentas of obese 
women without improving mitochondrial function (i.e. β-oxidation) increases neonatal adiposity, 
potentially due to greater lipid flux to the fetus. These data are consistent with our premise that 
lifestyle intervention pre-pregnancy can alter the progression of impaired β-oxidation to lipid 
accumulation and increased fat deposition, because changes in mitochondrial function may begin 
early in pregnancy. We expect that pregravid lifestyle intervention will result in improved placental 
mitochondrial function (i.e. β-oxidation), which will be measurable at term and associated with 
reduced fatty acid esterification and lipid accumulation, and result in lower neonatal fat mass 
accretion. 
 
Summary: These preliminary studies: 1) confirm our experience and expertise in conducting RCTs in 
pregnant women and their offspring; 2) show that the proposed lifestyle intervention approach achieves 
weight loss in obese adults and is feasible and successful in our hands; 3) provide strong clues as to which 
mechanisms of action  (including  placental  programming,  improved  β-cell  function,  and  reduced  
insulin  resistance)  are responsible for the improved glucose and lipid homeostasis in obese patients after 
weight loss interventions. Collectively, these data offer strong supportive evidence for the studies outlined 
next. 
 
Background and Significance 
 
Obesity during pregnancy: Obesity is a major health concern during pregnancy (4). In the United States 
55.8% of the female population aged 20-39 years is overweight or obese, based on body mass index 
(BMI, kg/m2) criteria (4). Further, 7.5% in this age group have a BMI >40 kg/m2 (5). Equally 
concerning, 17% of U.S. children and adolescents are obese (6) and mean term birth weight is increasing 
in developed nations (7, 8). We have reported a significant increase of 116 g in mean term birth weight in 
Cleveland since 1975 (9). High maternal pregravid BMI, and not gestational weight gain (GWG), was the 

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strongest correlate for a high birth weight. Although some have suggested that the increase in birth weight 
may have reached a plateau (10), we have found that this is secondary to factors such as earlier 
gestational age of delivery (11). Of greater concern is the significant increase in the Ponderal Index 
(weight/length3) in our neonatal population over the last decade (11). 
 
Pre-pregnancy obesity or excessive gestational weight gain - relationship to fetal overgrowth: 
In 2009 the Institute of Medicine (IOM) reexamined the 1990 GWG guidelines. Thirty-eight 
percent of normal weight, 63% of overweight, and 46% of obese women gained weight in excess 
of IOM guidelines (12). In Cleveland, 59% of overweight and 52% of obese women had excessive 
GWG. These percentages are higher in African American and Hispanic women. In obese women 
excessive GWG was a significant risk factor for cesarean delivery and postpartum weight retention, 
and not related to development of preeclampsia or gestational diabetes (GDM). High GWG was 
associated with an increased risk of preterm birth but was not related to increased risk of fetal 
overgrowth (12). Thus, excessive GWG is a primary risk factor for maternal post- partum weight 
retention, which increases the risk of maternal pregravid obesity in a subsequent pregnancy. 
 
Maternal obesity in early pregnancy more than doubles the risk of obesity in offspring between the 
ages of 2 to 4 (13). Boney reported that (LGA) neonates of mothers who were obese, and/or 
developed GDM, were at increased risk for developing the metabolic syndrome between ages 6 to 11 
(14). Maternal obesity but not GDM had a 2-fold greater risk for metabolic syndrome in the 
offspring. In our 8-10-year follow-up studies, maternal pregravid BMI, independent of GDM or 
GWG, was the strongest predictor of childhood obesity and metabolic dysfunction (15). In a meta-
analysis, Philipps reported that although maternal diabetes is associated with increased childhood 
BMI z-score, this was no longer significant when adjusted for maternal pre-pregnancy BMI (16). 
Hence, maternal pregravid obesity is not only a risk factor for offspring adiposity a t  birth, but 
also for the long-term r i s k  of obesity and metabolic d y sf u nc t i o n  i n  the offspring 
independent of maternal GDM or excessive GWG. 
 
RELEVANCE AND USEFULNESS OF THE OBJECTIVES 
 
Clinically, the proposed study provides feasible methods to improve the short and possibly long-term 
metabolic health of obese women and their offspring. Scientifically, this study will provide fundamental 
insights into the physiological and molecular mechanisms underlying maternal metabolism before 
pregnancy and effects on maternal/placental physiology. 
The actual lifestyle interventions (healthy eating and increased physical activity are not in 
themselves unique techniques in pregnancy. The uniqueness or innovation is the use of these 
techniques in order to affect an improvement in fetal adiposity in a subsequent pregnancy. Studies 
are not unique in pregnancy. The innovative aspects of this proposal are the following: 
1) The lifestyle intervention will begin prior to a subsequent pregnancy. We are uniquely 
positioned to recruit overweight/obese women immediately after  index pregnancy. This 
allows us to conduct a “run-in period” of actual recruitment and randomization by ~3 
calendar months (±27 days) postpartum. Our experienced research team is one of the few 
to successfully recruit large numbers of women prior to a planned pregnancy for 
metabolic studies. 
2) The period between pregnancies will allow sufficient time for the lifestyle intervention 
to decrease weight and result in improved insulin sensitivity, β-cell function, adiponectin   
concentrations   and   decreased inflammation, in contrast to lifestyle intervention 
initiated during the second trimester of pregnancy. 
3) This proposal has the potential to fulfill, by providing level 1 evidence one of the 
objectives of the 2009 IOM report. Research recommendation S-7 suggests that by 
providing pre-conceptual services to obese women, such as diet and physical activity, 

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with the goal of achieving a healthy weight before conceiving, will represent “a radical 
change to the care provided to obese women of childbearing age” (49). 
4)  Our proposal incorporates a trans-disciplinary team (nutrition, exercise physiology, 
molecular biology, obstetrics, and endocrinology). We will test our hypothesis that the 
intervention translates into cellular and molecular modifications relating to insulin action 
pathways. Only by employing a well-disciplined longitudinal program, based in the 
community with sufficient support, will our subjects recognize that lifestyle intervention 
represents a life course alteration that will have long-term benefits for both mother and 
child. 
Rationale: We conclude, based on our previous research (15, 50, 51, 52, 53, 54, 55, 56, 
57, 58), that maximum metabolic benefits relating to fetal body composition and 
metabolism can only be achieved by improving the pregravid metabolic condition of 
obese women. Therefore, Specific Aim 1a will examine how maternal lifestyle 
intervention initiated prior to a planned pregnancy results in improvements in maternal 
insulin sensitivity, β-cell function, adiponectin concentrations and a decreased 
inflammatory milieu.  Specific Aim 1b provides a physiological translational link 
between improved maternal metabolism and neonatal adiposity and metabolic condition.  
Specific Aim 2 will provide evidence that lifestyle intervention improves placental 
mitochondrial function and lipid oxidation, and decreases lipid esterification/storage 
thereby providing a mechanism whereby the maternal pre-pregnancy metabolic milieu 
regulates placental nutrient function and subsequent fetal growth.    
Is there an active control group?   
  
If Yes, describe the following: 
o The control group will be provided with current recommendations for healthy eating 
(myplate.gov) and exercise recommendations (American College of Sports Medicine; ACSM) to 
achieve a healthy lifestyle. Additionally, the control group will receive healthy pre-pregnancy and 
pregnancy guidelines from the American College of OB/GYN (ACOG). In brief, the control 
group will be asked to consume a balanced diet, limit added sugar and saturated fat and increase 
physical activity for 30 minutes a day for at least 5 days per week. 
o The lifestyle data to date during pregnancy has not shown any benefit of lifestyle interventions 
during pregnancy as compared to the control group. The hypothesis to be tested is that a lifestyle 
intervention BEFORE pregnancy will have benefit in a subsequent pregnancy. The information 
provided to the control subjects will in the vast majority of situations be of greater content, 
specifics and recommendations than are currently provided to overweight and obese women in 
clinical practice. 
o The control group will not be exposed to any risks beyond what is currently recommended by the 
ACOG for overweight and obese women planning a pregnancy, i.e. eating healthy food, 
increasing physical activity and return to pre-pregnancy weight. 
 
2.2 Risks to Subjects 
Adequacy of Protection Against Risks  
Risks include the following: 
 
Subjects will be asked to use an acceptable means of birth control at least until they have completed the 6-
month post-partum follow-up visit. The type of birth control they choose will be determined by them and 
their health care provider. There are no risks in performing the metabolic studies when pregnant; they will 
be performed at 12-16 and 32-36 weeks of pregnancy. We would not wish to perform them outside the 
defined study windows to avoid extra visits or obtaining blood that cannot be used as part of the research.  
 
Yes
No

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 When blood is drawn from a vein there will be some temporary discomfort and the minimal risk of local 
bruising, infection or blockage of the vein.  We will take suitable precautions including trained staff 
who are certified to draw blood in volunteer subjects using an indwelling catheter, and minimal size 
needles to obtain the samples will help to minimize these risks. 
 There are no risks to performing the Indirect Calorimetry to estimate resting energy expenditure. 
 The possible risks of the oral glucose tolerance test consist of occasional nausea and very rarely vomiting 
or lightheadedness.   
 There are no known risks from using the Bod Pod method to measure body fat composition. 
 For those randomized to the Lifestyle Intervention group, risks include possible injury such as muscle 
and joint sprains during the exercise sessions. 
 While exercising or performing the VO2 max test, subjects might experience fatigue or shortness of breath.  
They might also feel like their heart is pounding very fast or very hard and experience dizziness, heart 
rhythm abnormalities, chest pain, or very rarely a heart attack or death.  They could stumble and fall off 
the treadmill.  If subjects have any of these experiences, they are instructed to tell the research team.  
Also, when the mask is on their face, this might feel uncomfortable. 
 There are no known additional risks from performing the metabolic tests. 
 There is the potential risk of loss of confidentiality of the results of metabolic testing. We make every 
effort to minimize these risks by keeping paper records in a locked cabinet in a locked office. Any 
information held in electronic form will be kept on a secure computer in the research area of the 
hospital. Information containing personal data, for example birthday will be de-identified using a 
research hospital code number.  
 
Delivery: 
 Taking blood from the placenta and the umbilical cord will not harm subjects or their baby. 
 Measuring baby's length, weight and fat thickness will not hurt the baby. 
 There are no known risks to measuring baby’s body composition with the Pea Pod device.  It is possible 
that the baby will become upset while lying in the chamber of the Pea Pod during the 2-minute 
measurement period; however, the baby at no time will be subjected to any type of discomfort.  The 
baby is placed in a warm, molded plastic “infant seat” type structure.  The clear acrylic enclosure allows 
the infant to always be in the view of the operator.   
 There are no risks to mother or infant related to completing these questionnaires. We will instruct 
subjects that “Some questions on the questionnaires are of a sensitive nature and you may feel 
uncomfortable answering these questions. You can choose not to answer any questions you are not 
comfortable completing”.   
 
We will maintain contact with the subjects, via phone, email or text messaging and plan to 
meet with her at any of her postpartum visits to her obstetrical care provider. At that time 
study staff will review inclusion/exclusion criteria and review factors such as blood pressure 
and clinical OGTT if the patient had GDM. The study coordinator will also make sure that 
subjects who required a cesarean delivery will be able to partake in the lifestyle regimen if 
they are randomized into that group. The PI at each site will make final decision about 
eligibility. At this time, the potential subjects who agree to participate in the study will be 
scheduled for a metabolic evaluation visit at the Tufts CTRC and HNRCA, or the Brigham & 
Women’s Hospital (BWH) Research Facility at 221 Longwood prior to randomization. 
The consent document for this protocol will be approved by the Institutional Review Board 
(IRB) at Tufts Medical Center. Written informed consent will be obtained from all subjects 
participating in the project. 
 
b. Protection Against Risk 
The exercise component of the intervention at Tufts will be under the direction of Dr. Roger 
Fielding, a Co-I on this project. The exercise component of the intervention at BWH will be 

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under the direction of Dr. Kieran Reid. Methods to ensure safety with the exercise include 
screening for abnormalities on EKG and supervision by a certified lifestyle coach. At the time 
of the exercise testing in the HNRCA (VO2 testing), Dr. Fielding or Dr. Catalano will have 
available Dr. Lisa Ceglia to review any EKGs that he deems questionable. If there is an acute 
problem the subjects will be brought to the emergency Dept. at Tufts Medical Center. If there 
is a non-acute finding on the EKG the subject will be referred to her own PCP or if the 
subject does not have a PCP Dr. Ceglia will provide the name of a cardiologist. Subjects with 
a questionable cardiac history will either be excluded based on exclusion criteria of if 
questionable history at the time of explaining the protocol to the subject, we will ask that the 
subject be cleared by her own physician before being allowed to be included in the LIPP 
study. Similar precautions will be taken at BWH. 
 
In order to ensure safety with the nutrition intervention, all food provided to subjects as part 
of this study will be prepared by the HNRCA or BWH Research Facility research nutrition 
team in the metabolic kitchen of the HNRCA or Research Facility or if the visits are taking 
place at the CTRC, food provided will be prepared by the nutrition team in the Tufts Medical 
Center kitchen. The diet will be based upon the Mediterranean diet, which is an eating pattern 
that focuses on fruits, vegetables, legumes, nuts, lean proteins and fish, while limiting red 
meats and sweets high in added sugar. Additionally, olive oil is used as the main fat in the 
diet. The caloric needs of the participants in the lifestyle modification program will be 
calculated from resting metabolic rate, which will be measured by indirect calorimetry, 
adjusted initially by a factor of 1.3 to account for the exercise program. Further adjustment in 
caloric content will be made to attain a weight loss of >5% of pre-pregnancy weight or 
closest weight to pre-pregnancy based on best clinical data. This will be achieved by a 
negative caloric balance of 500 Kcal/day to attain a rate of weight loss of 1 lb/week. 
Participants will be instructed by the LIPP team so dietary intake includes healthy choices for 
fat (mono and polyunsaturated) and protein (fish, nuts, legumes, and poultry) and substitution 
of dietary fat and simple sugars by healthy carbohydrates (fruits, vegetables, whole grains). If 
weight loss is not being achieved, participants will be recommended to use meal 
replacements (commercially available) to facilitate caloric restriction as was used with great 
success in the Look AHEAD trial. Once the weight loss target is attained, subjects will enter 
into a maintenance dietary phase, the aim of which will be to maintain or reduce further 
weight (up to 15% of baseline weight). 
 
During pregnancy, subjects randomized to the lifestyle intervention program will be advised 
to maintain their exercise regimen as tolerated per ACSM and ACOG guidelines. During 
pregnancy, all subjects will have dietary recommendations based upon the ACOG guidelines 
and delivered by the clinical nutrition program at Tufts Medical Center and Brigham & 
Women’s Hospital in order to gain weight as recommended by the 2009 IOM guidelines. Drs. 
Catalano and Fielding will oversee the studies in the HNRCA and Dr. Reid and Dr. Sen will 
oversee the studies in the BWH Research Facility. 
 
The Specific Aims of this proposal require that we only include women who plan to become 
pregnant. We will include assessment of growth/body composition of their neonates as the 
primary outcome measure. As such, we anticipate that approximately 50% of the neonates 
will be male. We believe that because the investigators have broad experience with lifestyle 
interventions in non-pregnant women, metabolic studies during pregnancies and experience 
with neonatal measurements, that there will be minimal risk to the women and infants 
participating in this study. The PIs and CO-Is are all experienced clinicians and NIH funded 
investigators. The facilities of Brigham & Women’s Hospital, the HNRCA and Tufts Medical 
Center are located next to and within hospitals. The outpatient facilities where the lifestyle 

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interventions take place will be in the HNRCA, BWH Research Facility or community where 
the participants work and live. 
 
Medical intervention will be available for all subjects enrolled in this program for medical 
emergencies related to adverse events. If there is a chronic medical condition resulting from 
participation in this study, the subject will be responsible per Tufts MC IRB regulations. We have 
conducted randomized control trials in the past and have experience with using DSMBs. We have had 
no issue with either data entry or reporting of adverse events. 
 
• 
Subject identifier number will identify all of the material collected as part of the study. The 
information will be kept on the REDCap database. Any paper records will be kept in the study 
coordinator’s office in a locked cabinet. 
• 
There are no unknown risks to this study. The metabolic testing has been conducted by the PIs 
(Catalano at Tufts, Kirwan at the Pennington and Calles at Case Western) at each of the sites for a 
number of years with no adverse effects. The lifestyle intervention group will be under the 
supervision of trainers who will have employed healthy eating and exercise as a component of their 
research for a number of years. The intervention groups will be overseen by Kirwan (Case Western 
and the Pennington), Fielding (Tufts) and Reid (BWH and MGH). 
• 
The research nutritionist reviews the diets of each subject in the intervention arm and makes 
adjustments regarding the Mediterranean diet based on the individual’s specific food allergy. 
• 
There are no risks to the fetus or embryo for healthy eating and exercise during pregnancy as these 
are the current recommendations of the ACOG. If a woman becomes severely dehydrated, this could 
decrease blood flow and oxygen to the fetus. This situation is often accompanied by symptoms as 
noted above in the mother. Care will be taken to avoid these conditions because of the presence of 
certified trainers in the intervention group. 
• 
If applicable, describe risks to people other than the participating subject, e.g., risks to family 
members, friends, others or risks to the community. NA  
There may be benefit to the family because of women most commonly doing the greatest share of 
meal planning for the family. 
• 
If applicable, describe risks to study investigators or staff performing the study procedures due to 
research with high risk populations (e.g. prisoners, intravenous drug users, patients with major 
psychiatric issues, etc.). NA 
 
2.3 Potential Benefits to Subjects 
Potential Benefits of the Proposed Research to Human Subjects and Others 
 
There are potential benefits to subjects and others from this proposed research. The potential 
benefits to subjects in the lifestyle intervention arm are that they will be able to participate in 
a supervised diet and exercise program to decrease weight and improve metabolic function in 
preparation for a future pregnancy. If indeed the intervention proves successful, not only will 
there be immediate benefit to the subject herself, but there is the real possibility the 
intervention will have long term benefit for the prevention of obesity and metabolic 
complications for both the mother and her offspring. Even subjects assigned to the usual care 
or control arm of the study will have the benefit of being given specific advice as to an 
optimal diet and exercise regimen before pregnancy based on the metabolic evaluation in the 
HNRCA or CTRC in TMC and the Research Facility at 221 Longwood in BWH. While we 
call this usual care, the information the usual care subjects receive from their OB provider on 
lifestyle interventions for overweight and obese women is not nearly as detailed as the usual 
care subjects receive in the LIPP study. The metabolic results from testing will be available to 
the nutritionist and lifestyle coach. In routine clinical care neither this information nor a 

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detailed meeting with a nutritionist and lifestyle coach are available in the course of a routine 
postpartum visit.  
 
 
There are direct benefits to both the intervention and usual care groups as described previously. 
There will be a benefit to all subjects who are recruited from this study, i.e. women delivering at Tufts 
MC, Pennington, BWH or any other affiliated institutions participating in the LIPP study. 
 
Importance of the Knowledge Gained 
 
The importance of the knowledge to be gained by this proposal is the ability to determine if Lifestyle 
Interventions in Preparation for Pregnancy can achieve concrete (real) results in the efforts to stem the 
epidemic of obesity in women and their offspring. This study will also provide information as to the 
mechanisms of why lifestyle intervention before rather than only during pregnancy results in improved 
outcomes. Although the concept of pre-pregnancy lifestyle intervention has been recognized previously as 
potentially worthwhile, there have been few if any studies employing such a study design, because of the 
perceived difficulty in recruiting women prior to pregnancy. Based on our history of conducting research 
studies in women before during and after pregnancy, a study design of recruiting obese women 
immediately after their index pregnancy and incorporating the community into the lifestyle interventions, 
we believe that this approach will have applicability in many other populations. 
 
The risks to subjects are minimal. They are the standard of care we should provide to all our obese 
patients considering future pregnancy. Our ability to provide more than a minimal amount of information 
is hampered by the lack of resources particularly for women seeking care. If successful, as proof of 
principle, we believe this protocol can serve as a paradigm for a wider initiation of lifestyle interventions 
before pregnancy. 
 
We believe that the minimal risks associated with this proposal are reasonable in relation to the 
anticipated benefits, because to date much of the medical efforts relating to obesity have been 
focused on treatment; whereas, the goal of this proposal is not only treatment of the mother but 
prevention of obesity in her offspring. If successful this program will be expanded to include a 
much larger population; for example, potentially involving a larger multi-center approach or 
possibly involving the Maternal Fetal Medicine Networks. Last, we will also plan long-term 
follow-up studies of the mothers and their children to test the hypothesis that there are long-term 
benefits to lifestyle interventions in preparation for pregnancy. 
 
 
2.4 Alternatives 
• 
The alternatives to participating in this study are the routine information provided to overweight and 
obese women by their obstetrical health care provider at the time of their postpartum visit. 
• 
Overweight and obese women MAY be advised to increase physical activity and eat healthy but 
rarely see a nutritionist or a trainer about the specific lifestyle activity based on their baseline 
metabolic status. 
• 
Subjects could go to a reputable health club in the area and ask for a personal trainer and nutritionist 
for either a 1-time session (usual care) or sign up for personal training Intervention group). 
 
3 
Objectives 
• 
Describe the purpose, specific aims, or objectives of the study (i.e. the reason for performing the 
study in terms of the scientific question to be answered).  
Studies evaluating lifestyle intervention in obese women during pregnancy have reported 
limited success in decreasing excessive gestational weight gain, and have failed to achieve 

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the key outcome of breaking the obesity cycle and reducing neonatal adiposity or birth 
weight. Although some investigators advocate weight loss during pregnancy in obese women, 
these recommendations were based on extrapolation of retrospective epidemiological data. Of 
concern, we reported increased small for gestational age babies and decreased lean body mass 
in neonates of obese women with weight loss or inadequate gestational weight gain. Based on 
our research, optimal outcomes from lifestyle interventions are likely to be temporal and 
therefore must be initiated prior to conception to first improve maternal metabolic function, 
and subsequently, placental/fetal growth. Several large retrospective cohort studies support 
our hypothesis.  For example, women who lost weight between pregnancies had fewer large 
for gestational age babies in contrast to women who increased inter-pregnancy weight. In 
addition, prospective randomized controlled trials have shown that postpartum weight loss is 
achievable without adverse maternal or neonatal outcomes, these studies include women who 
breastfed. Based on these observations, we propose a randomized control trial to determine 
the effect of lifestyle intervention initiated prior to a planned pregnancy on improving 
neonatal metabolism and adiposity. 
 
Our over-arching hypothesis is that the maternal pre-pregnancy metabolic condition   
determines the obesogenic in-utero environment, which affects programming of placental 
mitochondrial function and metabolic pathways, promoting lipid accumulation and neonatal 
adiposity. Our rationale is based on the need to establish the most effective time to introduce 
an intervention that will break the obesity cycle in mothers and their children. Understanding 
how pregravid metabolic conditioning improves maternal physiology and cellular and 
molecular function in pregnancy will provide the empirical data to support the intervention. 
We have a highly successful record of - recruiting women who are planning a pregnancy, 
obtaining compliance in longitudinal studies, and in long-term follow-up of mothers and their 
offspring. Lifestyle intervention will be initiated prior to conception to decrease maternal 
body fat, inflammation, insulin resistance, and β-cell dysfunction. Our trans- disciplinary 
team has the required expertise in lifestyle interventions, management of obesity, and in 
human physiology that is needed to determine the effects of these interventions on maternal 
metabolism and fetal- placental growth and function. We will recruit 200 women to pursue 
the following specific aims: 
 
Specific Aim 1: To investigate the physiological significance of lifestyle intervention in 
preparation for pregnancy (LIPP) on maternal and neonatal metabolism and adiposity. 
 
Sub-Aim 1a. The working hypothesis is that a lifestyle intervention, initiated after the index 
pregnancy, will facilitate lower maternal insulin resistance, inflammation, weight, adiposity, 
incretin response, and energy expenditure compared to usual care. We will perform 
longitudinal measures of body composition, insulin sensitivity and secretion   and blood 
markers of inflammation. We will link these changes to improvements in neonatal adiposity 
and insulin sensitivity. 
 
Sub-Aim 1b. The working hypothesis is that women who initiate a lifestyle intervention 
before the subsequent pregnancy will deliver a baby with lower birth weight and fat 
accretion; insulin resistance; and cord blood markers of inflammation. We will measure body 
composition using anthropometrics and air displacement plethysmography (Pea Pod), 
umbilical cord glucose, insulin, leptin, IL-6, hsCRP, and adiponectin. 
 
Specific Aim 2:  To determine the molecular effects whereby lifestyle intervention initiated 
before pregnancy can improve placental mitochondrial lipid oxidation and accumulation. 
The working hypothesis is that lifestyle intervention before pregnancy will increase placental 
mitochondrial lipid oxidation and decrease lipid esterification/storage (Fig. 2). Isotope-

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labeled fatty acid oxidation and esterification will be quantified in vitro in placental explants.  
We will measure markers of mitochondrial lipid metabolism and content using qRT-PCR and 
ELISA approaches. Placental lipids will be quantified and correlated with neonatal adiposity 
and maternal metabolism. 
 
Impact of the study:  Clinically, the proposal provides feasible methods to improve short and long-
term metabolic health of obese women and their offspring. Scientifically, this study will provide 
fundamental insights into the physiological and molecular mechanisms underlying maternal pregravid 
metabolism and effects on maternal/placental physiology. 
 
Specify which are the primary or secondary aims or objectives of this study as applicable.  
The primary objective is the main question. Secondary objectives are goals that will provide further 
information for the study  
We have not developed secondary aims for the study. These will be considered once the primary 
study is underway and secondary funding is sought. For example, we are in preliminary discussions 
with Dr. Economos in the school of nutrition to look at any spillover effect of the LIPP study on other 
family members. These discussions are at the initial stages and have not yet been fully developed or 
sought additional research funds.  
 
4 
Enrollment and Withdrawal  
4.1 Inclusion Criteria 
• 
Describe the criteria that define who will be included in the study as a numbered list. 
Human Subjects Involvement, Characteristics and Design 
We will recruit a total of 100 in the Greater Boston area and 100 in the Greater Baton Rouge area (PBRC)) 
overweight/obese subjects (defined as pregravid BMI 25-35 kg/m2, and 23-32.5 kg/m2 for Asian 
populations as defined by the WHO guidelines, 95) at the time of their index pregnancy, hereafter defined 
as obese for the purposes of the proposal) determined by review of the electronic medical record (EMR) 
after delivery of their index child. 
Inclusion criteria: 
All subjects will meet the following criteria by the time of randomization at 3 calendar months postpartum: 
1) Planning another pregnancy within the next 24 months 
2) Planning to deliver in the greater Boston or Baton Rouge area during their next pregnancy 
3) A previous full-term singleton pregnancy (gestational age > 37 weeks) 
4) 18 to 40 years of age at the time of enrollment into the study 
5) Vaginal or cesarean delivery 
6) Normal glucose tolerance or gestational diabetes (GDM), but without evidence of postpartum diabetes 
as defined by a 75 g 2-hr oral glucose tolerance test (OGTT) or HbA1c per ADA criteria. 
7) Normal blood pressure or mild preeclampsia but postpartum blood pressure not requiring medication 
8) Bottle or breast feeding 
9) Normal thyroid function (determined by TSH concentration in blood), normal blood cell count and 
normal kidney and liver functions. Lipid profile with triglyceride 0levels not higher than 400 mg/dl 
(fasting) and LDL levels not higher than 200 mg/dL (if levels are above 180 mg/dL, potential participant 
should attain approval via letter from their PCP/OB).  
11) No clinical signs or symptoms of cardiovascular disease or any other disease or condition that may 
contraindicate participation in exercise training (i.e. COPD, 2Severe asthma, orthopedic abnormalities) 
13) Using contraception 
o Indicate specifically whether you will include any of the following special populations:  
o Pregnant women  yes 
o Lower age limit is 18 
 

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4.2 Exclusion Criteria 
• 
Describe the criteria that define who will be excluded in the study as a numbered list. 
All subjects will NOT meet the following criteria:1) Pre- or post-delivery diabetes 
2) Post-delivery hypertension requiring medication 
3) Asthma requiring more than occasional use of a sympathomimetic inhaler, but not chronic inhaled 
steroids 
4) Inflammatory bowel disease 
5) Need for any assisted reproductive technologies to become pregnant based on best clinical judgement 
6) Medical or obstetrical contraindication to the defined exercise program or diet 
7) Tobacco, excessive alcohol use (greater than 2 drinks/day) or illicit drug use 
8) Eating disorders such as bulimia 
9) Gastric surgery to lose weight including banding or bypass procedures 
10) Any psychological or psychiatric condition that may impair participation in the lifestyle intervention 
program 
11) Multiple pregnancy 
12) HIV, or hepatitis B or C based on patient’s history 
13) Congenital heart disease unless accompanied by a letter from the subject’s cardiologist clearing them to 
exercise  
• 
Specify whether a study subject may participate in another research study while participating in this 
research study.  
Yes as long as there is no conflict with LIPP as the primary research study. 
 
4.3 Withdrawal of Subjects 
Subjects who do not become pregnant at the end of the intervention or usual care component (21 months 
postpartum) are still included in the study. They will not undergo further evaluation but will continue to 
be followed until either they become pregnant or the study terminates. Contact will be maintained through 
a brief monthly check-in phone call from study staff. For the intervention arm, this will include a 
reminder of body weight goal and strategies to sustain weight loss. Testing will resume during pregnancy 
at the specified intervals of 12-16 and 32 to 36 weeks of pregnancy. 
• 
Describe anticipated circumstances under which subjects will be withdrawn from the research 
without their consent. 
We have had subjects we asked to withdraw from the study because of their not returning for their 
metabolic assessments in the metabolic research centers, no shows at scheduled training sessions, 
smoking (which is an exclusion criteria). 
If a LIPP subject becomes pregnant prior to 16 weeks after randomization or becomes pregnant before the 
3-month postpartum randomization, i.e. no baseline measurement, they would be asked to withdraw. 
• 
Describe procedures that will be followed when subjects withdraw or are withdrawn from the 
research, including the possibility of partial withdrawal from study intervention with continued data 
collection.  
We will plan to maintain demographic data for subjects who have withdrawn from the study in order 
to compare with subjects who have been compliant with the study protocol in order to determine if 
there was bias in subject compliance. 
• 
Include any necessary safety precautions to be applied to subjects who withdraw or are withdrawn 
(tapering drug doses, evaluative x-ray, etc.).  NA 
 
4.4 Recruitment and Retention 
4.4.1 Local Recruitment Methods 
Describe the following attributes of the recruitment plan for the local Tufts site:  
• 
When, where, and how potential subjects will be recruited.  
• 
We plan to approach subjects, assuming they and their newborn are stable, on the 
postpartum unit of Tufts Medical Center (Tufts MC) after their delivery. The PI and/or 

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the study coordinator will inform the subjects about the study.  Subjects will be identified 
as being eligible based on information obtained at the time of their delivery. Potential 
subjects will be interviewed by the PI and/or the study coordinator to determine 
eligibility and potential interest in the LIPP project. They will be given a brochure 
describing the study. If potentially interested we will obtain contact information, such as 
email and phone numbers and contact potential subjects prior to their 4-6 week 
postpartum visit. Before their postpartum visit with their OB health care provider, study 
staff will contact them to determine if they might be interested in participating in the 
LIPP study. If they are, one of the recruiters will meet the subject at their postpartum 
visit, explain the study in more detail, and provide the potential subject with a copy of the 
consent form. The subjects will have until 3 calendar months (+/- 3 full weeks) to decide 
to join the study and be scheduled for metabolic testing. We created an IRB-approved 
informational website that is linked to on the MIRI lab page at Tufts MC and distributes 
ads via social media and print linking to the informational website. If a potential 
participant would like to ask questions related to the study to a current or former 
participant, LIPP study staff will initiate this communication (via email, text or phone 
call) with the approval of both individuals.  
• 
Source of subjects (for example, patient population, local community, etc.).  
Postpartum patients at TMC. 
• 
Methods that will be used to identify potential subjects.  
Review of EMR charts. Patients who are found to meet exclusion criteria during screening, such 
as history of HIV, or hepatitis B or C, will not be recruited and their PHI will not be recorded. 
• 
Materials that will be used to recruit subjects.  
Primarily brochures and speaking with potential subjects, as well as sharing the study website 
page with those who are interested. The brochure will be given to all potential subjects until we 
have reached our recruitment goals.  
• 
When subjects respond to recruitment material, describe the information that will be provided to 
them about the study and the information that will be collected from subjects (e.g. name, 
telephone number, etc.) or submit a telephone/email script that will be used.  
We do not use a script. Subjects will be given a copy of the brochure and if interested will be 
given a copy of the consent form to be reviewed with the study coordinator. 
o If data will be retained for subjects that are determined to be ineligible, specify how 
privacy and confidentiality of these potential subjects will be maintained. Data will be 
retained until the primary manuscript is written noting differences in the study population 
that have determined to be ineligible for whatever reason based on inclusion/exclusion 
criteria. 
o Also, submit the screening log to the IRB for review.  
The screening log template has been submitted with the application. 
o We will retain non PHI information number of subjects etc. who are determined not to be 
eligible.  
o Please refer to the DSMB reports we have submitted. 
• 
If recruitment material is being mailed or otherwise distributed, describe where/how, the 
distribution list will be obtained.  
The information will be given to potential subjects at the time of the postpartum visit. The same 
brochure will be sent via email to potential subjects prior to their postpartum visit to remind them 
of the specifics of the LIPP study. 
• 
Specify how and why the listed recruitment methods will be effective in attracting the targeted 
subject population.  
The recruitment methods have been successful in recruiting the first 20 subjects in Cleveland at 
MetroHealth Medical Center.  
 

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4.4.2 Study-Wide Recruitment Methods 
Is this is a multicenter study where subjects will be recruited by methods not under the control of 
the local Tufts site (e.g., call centers, national advertisements)?  
 
If Yes, describe the following: 
• 
Methods of recruitment not under the control of the local Tufts site. 
There will be no further recruitment at the Pennington site in Baton Rouge; we will continue to follow 
subjects until they deliver at the PBRC (please see section 11.1 for site specific information). There will 
also be no further recruitment at Massachusetts General Hospital (MGH) but recruitment will occur at 
Brigham and Women’s Hospital (BWH) in Boston in coordination with TMC. Potential participants in 
the Lifestyle Intervention in Preparation for Pregnancy (LIPP) study will be recruited from eligible 
women who have delivered infants at BWH. Women will be approached on the Labor and Delivery and 
Postpartum units of BWH following delivery of their infant following a screening of medical records for 
exclusions including entering restrictive charts (‘breaking the glass’). Women who express interest will be 
given an IRB approved flyer and contact information will be collected. Contact information will be 
transferred to Tufts study staff via a Mass General Brigham maintained secure Dropbox. Tufts study staff 
will reach out by email, phone, or mail to women who agree to be contacted and will offer study 
participation. As an alternative to in-person recruitment, women who are missed in-person will receive a 
letter via the Mass General Brigham patient portal with an opt-out option. If women do not opt-out, the 
LIPP study staff will contact them in 3-4 weeks via email or phone number by way of the listed contact 
information in their medical records. All subsequent study procedures will be conducted at TMC and 
BWH for those women who elect to participate. For women who deliver at MGH or BWH, delivery 
protocol will be followed accordingly for each site. At the time of delivery, LIPP study staff from all 
Boston-area sites (MGH, BWH and TMC) will collect study sample data, maternal and infant data from 
medical charts, and conduct maternal questionnaires. 
 
• 
When, where, and how potential subjects will be recruited. 
Brigham and Women’s Hospital (BWH) in Boston, MA. 
• 
Methods that will be used to identify potential subjects. 
Similar to what we will use at Tufts. Data will be provided if requested and have IRB approval. 
• 
Materials that will be used to recruit subjects.  
Submit a copy of each recruitment-related document with the application. For advertisements, 
attach the final copy of the print advertisement. When advertisements are audiotaped or 
videotaped for broadcast, attach the final audio/video. You may submit a script of the proposed 
audio or video advertisement for IRB review before taping the final version in case revisions are 
requested. Once recommended changes are made, the final version is to be submitted to the IRB 
for review and final approval.  
 
4.4.3 Payment  
Will subjects receive money, gifts, or any other incentive for participating in this study?  
This does not include reimbursement for expenses, which is considered in the next section.                    
     
If Yes, describe the following: 
• 
Any proposed payment or incentive for subjects (e.g., a specific description of the incentive, its 
value both in US and local currency [if international], local household income information, 
provided to whom). State if the payment/incentive value could pose undue influence on the subject’s 
decision to participate. Subjects in the intervention group  
• 
Payment amount. 
 
PAYMENT  
Yes
No
Yes
No

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Subjects randomized to the LIPP group, will receive up to approximately $2500 of value as follows:  
• 
$40 for the first study metabolic visit, $50 for the second study visit, and each study visit will then increase by 
$10. The total compensation of the seven study visits is $490 for participation in this study.   
• 
The study will provide 750 ml bottles of extra virgin olive oil (EVOO) throughout the study.  
• 
If a subject withdraws from the study, they will be paid for the portion of the study that they have completed.  
• 
After delivery and the measurements of the baby have been completed, subjects will receive a $50 gift card for 
completing the study. 
• 
Subjects will be compensated for the cost of parking while at the research visit. 
• 
Taxi or public transportation services to and from the study visit can be arranged at no expense to subjects, if 
needed. Costs for childcare may be reimbursed during LIPP visits or training if needed.  
• 
A FitBit system to track step count, exercise time, and body weight throughout the study will be provided. 
• 
Subjects will receive free access to the exercise facilities used in the study or we will provide a membership to 
an exercise facility until subjects become pregnant or for a period of up to 24 months.  
 
Subjects randomized to the usual care (control) group, will also receive up to approximately $2250:  
• 
$250.00 per each of the 7 metabolic visits, with a $500.00 study completion bonus at the end of the study. The 
maximum number of visits is seven (5 postpartum and 2 during pregnancy) for a total payment of up to $2,250. 
• 
Subjects will be compensated for the cost of parking while at the research visit. 
• 
Taxi or public transportation services to and from the study visit can be arranged at no expense if needed. Costs 
for childcare may be reimbursed during LIPP visits or training if needed in accordance with the local site 
average amount per hour for the duration of the visit (see below- LIPP Childcare).  
• 
How payment will be made (e.g., cash, check, Greenphire ClinCard).  
Payment will be made using a pre-paid debit card, i.e. Greenphire ClinCard. Subjects who are legally unable 
to accept payment from Tufts Medical Center (e.g. subjects on a student or work visa) will receive store or 
credit card gift cards as tokens of appreciation. 
• 
To whom payment will be made (subject, parent [which one], LAR). 
Payment will be made to the study participant. 
• 
When payment will occur.  
Payment will occur after each study visit and after delivery and measurement of the baby. 
• 
The payment schedule to be used, including the payment schedule and amount for subjects who withdraw or 
are withdrawn from the study.  
Please see above. 
 
4.4.4 Reimbursement   
Will subjects be reimbursed for their expenses, such as travel, parking, meals, or any other study related 
costs? 
   
                                  
If Yes, describe the reimbursement plan and procedures, including: 
• 
What qualifies for reimbursement and whether pre-approval is needed.  
All subjects will be reimbursed for parking or transportation for study visits.  Subjects in the 
intervention arm of the study will be reimbursed for a membership in an exercise facility, 
transportation to the exercise facility and childcare if needed.  
• 
How subjects will be required to document expenses for reimbursement (e.g., provide receipts). 
Expenses will be paid either through providing receipts or through arrangements with the exercise 
facilities directly to the LIPP grant through Research administration. 
• 
How and how often subjects will request reimbursement.  
Subjects can request after each study visit. Subjects in the intervention arm can request 
reimbursement on a monthly basis for transportation to exercise facilities, travel to the exercise 
facility or childcare if needed. 
Yes
No

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• 
How reimbursement will be made (e.g., cash, check, Greenphire ClinCard).  
Greenphire ClinCard 
• 
The reimbursement schedule (when will subjects be reimbursed) 
Please see above. 
Consider developing a handout to provide to subjects detailing the above information. NA 
 
LIPP Childcare  
In order to support the LIPP research and create ease for participating mothers, the LIPP Study will offer support 
to mothers with childcare costs for the duration of a visit. This will be done when requested by participants. 
Participants will be required to show a form of evidence of cost (i.e., receipt, Venmo screenshot, etc.) for the 
study records. Upon approval by coordinator and/or principal investigator, participants will be reimbursed through 
their ClinCard. In accordance with the 2020 regional average of babysitting childcare in the Boston area, the study 
will reimburse up to $19/hour during the allotted visit time. Below are the expected visit durations and extent of 
coverage possible:  
Visit 1-5: 6 hours → childcare covered up to 7 hours x $19 = $133.00   
 
 
5 
Study Design 
5.1 Study Timelines 
• 
Describe the duration of an individual subject’s participation in the study. 
The time that the subject will be in the study is variable. The minimum time is 13 months (4 months 
in study and 9 months of pregnancy). The maximum time is 28+ months. The pre-pregnancy 
component of the study is variable. We list 18 months in study/21 months post-partum but if the 
subject becomes pregnant after 21 months post-partum, she will be followed in the pregnancy 
component. Hence, we list 28+ months. 
• 
Describe the duration anticipated to enroll all study subjects at the Tufts study site.  
Subjects will have their initial testing and randomization 3 calendar months (+/- 3 full weeks) after 
their delivery. Enrollment begins when the Informed Consent is signed. 
• 
Describe the estimated date for investigators to complete this study (complete primary analyses). 
The initial grant ended on 11/30/2022 and we are on an approved no-cost extension until 11/30/2023. 
• 
Describe the study procedures that will be accomplished at each study visit.  
At the HNRCA, CTRC or BWH Research Facility, the following metabolic testing/procedures will be 
performed: 
Metabolic evaluations will be performed at baseline (3 months ± 3 full weeks 
postpartum). Follow-up evaluations will be performed after 6 (± 3 full weeks) and 9 
months (± 3 full weeks), 15 (± 3 full weeks) and 21 months (± 3 full weeks) prior to 
pregnancy (Figure at the top of the protocol form) up to a maximum of 18 months. Once 
a subject becomes pregnant and has dating and viability confirmed by ultrasound, 
metabolic evaluations will continue at 12-16 and 32-36 weeks of gestation. However, if 
an individual participant has scheduling issues or there are extenuating circumstances 
with scheduling visits, we may schedule outside of the above windows.  
 
Maternal Body Composition: Anthropometry measurements will include height, weight, 
and hip and waist circumferences. Total body fat will be measured by whole body 
plethysmography (Bod Pod; Cosmed, Rome, Italy), (70). We will use a hydration 
constant of 76% for fat free mass during late pregnancy (71). If a BodPod is not available 
we will use skin calipers to take skinfold measurements of the triceps and mid-axillary 
skinfold to estimate body fat.  
 
Resting Energy Expenditure: Resting Metabolic Rate (RMR) will be determined after an 
overnight fast using the Cosmed OMNIA metabolic cart (Cosmed, Rome Italy) with a 

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canopy system. Participants will relax in a quiet low-light metabolic room for 30 min 
prior to obtaining a 30-min measure of exhaled breath. Oxidative glucose metabolism 
will be estimated and urine samples will be obtained before and after the measure in 
order to calculate non-protein RQ (NPRQ). These data will be used in conjunction with 
Specific Aim 2 and will be correlated with placental mitochondrial function during 
pregnancy. 
 
Exercise Capacity: An incremental graded treadmill test will be performed at baseline 
(3), 6, 9, 15, & 21 months postpartum time points in both groups. In addition, for the 
intervention group additional VO2 max testing will be performed at approximately 4 & 5 
months postpartum. Oxygen consumption, heart rate, and ratings of perceived exertion 
will be performed as previously described (48, 64, 65, 72). 
 
Insulin Sensitivity and β-Cell Function: A 75 g oral glucose tolerance test (OGTT) will 
be used to assess postprandial glycemia, and insulin sensitivity and secretion. After an 
overnight fast, blood samples will be drawn at -10, 0, 30, 60, 90, 120, & 180 minute time 
points. C-peptide data will be analyzed using a combined model approach to provide pre-
hepatic insulin secretion rates, insulin sensitivity, disposition index, and relate insulin and 
C-peptide kinetics (73). Plasma glucose will be measured using the glucose oxidase 
method (YSI; Yellow Springs, OH). Insulin will be assayed by RIA (Millipore, Billerica, 
MA). A fasting blood sample will be collected in lieu of the OGTT during pregnancy 
visits when there is a lack of funding. The OGTT will be collected during pregnancy 
again if additional funding is secured. 
 
Enteroinsular Axis Responses:  Plasma samples (with appropriate additives) will be 
obtained to measure incretin hormones (glucagon-like peptide-1 (GLP-1), and glucose-
dependent insulinotropic polypeptide (GIP), and satiety-related gut peptides 
(cholecystokinin (CCK), and peptide YY (PYY). Measurements will be made under 
static (fasting) and dynamic (glucose-stimulated) conditions. Blood samples for these 
incretin measurements will not be collected when there is a lack of funding, but may be 
collected again if additional funding is secured. 
 
Metabolic and Inflammatory Biomarkers:  Fasting blood samples will be obtained to 
measure CBC, TSH, HbA1c, lipid panel, and total free fatty acids (FFA). Adipocytokines 
(adiponectin, leptin interleukin-6, interleukin-8, TNF-α and hsCRP) will be measured 
using ELISA (R&D Systems, Minneapolis, MN). All samples from each subject will be 
stored at -80ºC and run in the same assay at completion to decrease variability. 
 
Questionnaires: IRB approved questionnaires will be administered at each visit that capture 
changes in lifestyle, mood, breastfeeding status, diet and exercise. These data will provide a 
generic measure of physical and mental health through assessment of physical functioning, bodily 
pain, limitations due to physical, personal, or emotional problems and well-being, energy/fatigue, 
and general health perceptions. During pregnancy the questionnaires will be administered at 12-
16 and 32-36 weeks gestational age, either at visits or over the phone. Diet information may be 
collected via an electronic interface, the ASA24 (see “Electronic Diet Data Collection” below). 
 
For women who deliver at MGH or BWH, delivery protocol will be followed accordingly for 
each site. At the time of delivery, LIPP study staff from all Boston-area sites (MGH, BWH and 
TMC) will collect study sample data, maternal and infant data from medical charts, and conduct 
maternal questionnaires. 
 

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Addendum: In cases where there are adverse conditions in which samples cannot be obtained for 
lab results or in instances where there is equipment failure, measures may be repeated for 
accurate time point data with the participant’s consent. 
 
Neonatal measures 
Measuring Fat Mass in the Infant:  We have extensive experience in estimating body composition 
in neonates (77,78,79,80,81,82,83,84,85,86,87,88), and were one of the first centers to procure a 
Pea Pod (pediatric air densitometry), which is housed in the neonatal intensive care nursery at 
TMC. 
 
Insulin Resistance at Birth: At birth we will obtain umbilical cord blood for insulin, C-peptide 
and glucose to estimate insulin resistance using HOMA (89). Full lipid profile, CRP, and the 
adipokines IL-6 and leptin (an excellent marker of neonatal fat mass) will be measured in cord 
blood as described above. 
 
Usual Care Group 
• 
Subjects assigned to this group, will receive normal standard of care that includes advice 
and recommendations to improve their health and will be monitored by the study staff. 
This will be provided via electronic communication or at the time of the exercise capacity 
test at the HNRCA or BWH Research Facility. 
• 
Subjects receive information on post-pregnancy diet/weight loss from our research staff.  
 
Lifestyle Intervention in Preparation for Pregnancy Group (LIPP) 
• 
Subjects randomized to this group will participate in a supervised diet and exercise 
program. They will work with personal trainers and Lifestyle Coaches to assure safety 
and compliance to the intervention.  
• 
Dietary Intervention (Weight Loss): During the first 12-weeks of lifestyle intervention, 
we will lower the amount of food subjects eat daily with an emphasis on eating healthy 
foods, and replacing those unhealthy foods with healthy fats, like the fats found in extra 
virgin olive oil (i.e., a Mediterranean dietary pattern).  To help with this change, subjects 
will be provided with 750 ml bottles of extra virgin olive oil as needed throughout the 
study.  Every 2 weeks, subjects will record their food intake for 24 hours using a phone 
app. Nutrition counseling will also be performed utilizing an app. The app is called 
MyFitnessPal. It is free and will be provided with instructions on how to download it 
(from the App Store). It consumes approximately 160 megabytes, which is a fraction of a 
percent of a typical 15 GB phone and will sync with the FitBit. For subjects who have 
difficulty in tracking meals, a variety of behavioral techniques (goal setting, self-
monitoring, and general nutrition education) as administered by the lifestyle 
interventionist will be used to increase compliance. 
• 
Supervised Exercise Intervention: During the first 12-weeks of the program, subjects 
will exercise 3-5 days each week for up to 60 minutes each day. The exercise will consist 
of walking/jogging on a treadmill, cycle and/or elliptical. Sessions will be conducted at 
the HNRCA, BWH Research Facility or an exercise/fitness facility in their area. Subjects 
will not be required to have a pregnancy test for each of their supervised exercise 
sessions. However, if they think they may be pregnant they will be told to inform their 
trainer. Subjects will be instructed to keep their heart rate within a prescribed limit (80-
85% of maximum) and will be provided with a heart rate monitor and watch to make it 
easy to check their heart rate. They will also be provided with a FitBit system (including 
an Aria electronic scale) to track step count and metabolic functions (e.g. heart rate, body 
weight). They will be allowed to keep the FitBit at the conclusion of the study. Subjects 
will be instructed to wear the FitBit throughout the day and a heart rate monitor when 

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exercising and to notify the investigators if there is any change in their medications 
(prescription, over-the-counter, herbals) during the period of this study. All exercise 
sessions will be recorded in an exercise training log and supervised by a certified exercise 
physiologist/trainer. There are cases where this supervision may occur remotely if 
necessary. 
• 
Dietary Intervention (Weight Maintenance): During the first phase of weight 
maintenance (2A) subjects will attend approximately 2 supervised group sessions per 
week. Each session will last approximately 60 minutes. These sessions will include 
structured exercise (e.g., Zumba, jazzercise, stroller walking) and we will review 
subjects’ diet records.  
• 
After 3 months and the desired weight loss, subjects will move to the next Phase (2B). 
During this phase, subjects will be required to attend approximately 1 supervised session 
per week. If they do not maintain their weight loss, they will return to the previous phase 
for more supervised weight management. Alternatively, if they maintain their weight loss 
after 3 months, they will progress to the third Phase (2C) of the program until they 
become pregnant.  
• 
The third phase (2C) consists of no supervised exercise sessions. However, subjects and 
their Lifestyle Coach will talk on the phone weekly to review their progress, including 
FitBit exercise data, weight, and diet. Each telephone call is expected to last 
approximately 5 minutes. 
• 
Electronic Diet Data Collection: Dietary assessment is a standard-of-practice for 
clinical trials. The ASA24, or Automated Self-Administered 24-hour (ASA24) Dietary 
Assessment Tool, is a web-based tool that enables multiple, automatically coded, self-
administered 24-hour dietary recalls. The ASA24 guides participants through steps to 
record all foods and beverages they have consumed over 24-72 hours.  The ASA24 was 
developed by the National Cancer Institute at the National Institutes of Health and has 
been validated for accuracy. 
• 
Participants will be assigned an ASA24 ID, Username and Password from each study 
site. 
• 
The 24-hour recall usually takes 20–30 minutes, a similar length of time if an in-person 
24-hour recall was conducted. 
• 
The format and design of the ASA24 are modeled on the interviewer-administered 
Automated Multiple Pass Method 24-hour recall developed by the US Department of 
Agriculture (USDA). This recall requires multi-level food probes to accurately assess 
food types and amounts. 
• 
The ASA24 software (most recent version ASA24-2020) is programmed with a food 
database which includes all foods available from USDA's Food and Nutrient Database for 
Dietary Studies (FNDDS) database. In addition, the software includes pictures of foods in 
multiple portion sizes to help respondents estimate portion size. 
• 
Data files include nutrients, foods, pyramid food groups, and Healthy Eating Index (HEI) 
variables. The software can quickly compute nutrient and food group estimates for each 
recall day. The software also has the capacity to accommodate languages other than 
English. 
 
 Respondent confidentiality is maintained within ASA24 
• 
ASA2 does not collect any identifying data about Respondents, either from Researchers 
or directly from Respondents. 
• 
Respondent data are protected by industry standard security controls. All data entered 
into ASA2 at the Respondent’s computer are encrypted by the Internet browser (e.g., 
Internet Explorer, Firefox) before they are transmitted to ASA24 servers using Secure 

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Socket Layer protocol, or SSL. SSL allows for the authentication of the sending and 
receiving computers. 
• 
Only a particular study’s investigator (study PIs, intervention staff) and the ASA24 
operations team can access response data using usernames and strong passwords. 
• 
IP address information is accessed for the purpose of routing information between the 
server and the Respondent’s computer. Often, the IP address is that of the user’s Internet 
Service Provider (ISP). IP addresses are not stored or tracked by ASA24.  
 
Virtual Sessions 
• 
Counseling sessions for either the control or intervention groups may be conducted via a virtual 
format (Zoom, etc). 
• 
These sessions may be one-on-one or group sessions discussing the control/intervention counseling 
information described above. 
• 
Participants will be provided a secure link and, if it is a group session, advised on the group nature of 
the sessions. Participants are asked NOT to share the personalized, secure link to anyone else to 
protect the privacy of each participant. 
 
For both groups, once healthy pregnancy is confirmed, we will notify subjects’ obstetrical 
healthcare provider regarding their participation in the study. Subjects will be asked to follow a 
diet for healthy weight gain during pregnancy and to maintain moderate physical activity based 
upon their level of physical activity before pregnancy based on ACOG guidelines and their 
primary obstetrical care provider. All subjects will be provided with the ACOG patient 
information guides on healthy eating and exercise during pregnancy. They will have a repeat of 
all the studies excluding VO2 max testing at TMC, the HNRCA or BWH Research Facility as 
described previously at 12-16 weeks and 32-36 weeks of pregnancy.  
 
Below is a detailed schedule for all planned evaluations and screenings associated with the study as described 
above, if additional funding is secured: 
 
3 months post-partum 
Randomization 
4 months post-partum 
5 months post-partum 
6 months post-partum 
9months post-partum 
15 months post-partum 
21 months post-partum 
Pregnancy 
12 - 16 weeks 
32 - 36 weeks 
Delivery 
CRU Visit - LIPP & Usual care groups 
Baseline Laboratory  
studies 
X 
Resting Metabolic Rate 
X 
X 
X 
X 
X 
X 
X 
OGTT 
X 
X 
X 
X 
X 
X 
X 
Body composition 
X 
X 
X 
X 
X 
X 
X 
Neonatal 
measurements 
X 
Placental 
measurements 
X 
LIPP Group 

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Exercise Tolerance 
X 
X 
X 
X 
X 
X 
X 
Nutritional assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
3-5 Days/Week 
Supervised exercise 
intervention 
X 
X 
X 
X 
Weight maintenance 
phases 2A, 2B or 2C 
X 
X 
X 
X 
X 
Usual care group 
Exercise Tolerance 
X 
X 
X 
X 
X 
Nutritional assessment 
X 
X 
X 
X 
X 
X 
X 
 
Below is the schedule for all planned evaluations and screenings, if there is a lack of funding: 
 
3 months post-partum 
Randomization 
4 months post-partum 
5 months post-partum 
6 months post-partum 
9months post-partum 
15 months post-partum 
21 months post-partum 
Pregnancy 
12 - 16 weeks 
32 - 36 weeks 
Delivery 
CRU Visit - LIPP & Usual care groups 
Baseline Laboratory  
studies 
X 
Resting Metabolic Rate 
X 
X 
X 
X 
X 
X 
X 
OGTT 
X 
X 
X 
X 
X 
 
 
Fasting Blood Draw 
X 
X 
Body composition 
X 
X 
X 
X 
X 
X 
X 
Neonatal 
measurements 
X 
Placental 
measurements 
X 
LIPP Group 
Exercise Tolerance 
X 
X 
X 
X 
X 
X 
X 
Nutritional assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
3-5 Days/Week 
Supervised exercise 
intervention 
X 
X 
X 
X 
Weight maintenance 
phases 2A, 2B or 2C 
X 
X 
X 
X 
X 
Usual care group 
Exercise Tolerance 
X 
X 
X 
X 
X 

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Nutritional assessment 
X 
X 
X 
X 
X 
X 
X 
 
5.2 Procedures 
• 
Is there a placebo control arm?  
  
If Yes, describe the following: 
o The scientific, methodological, and medical reasons to use a placebo.  
There is no placebo per se. We are using the term usual care.  
o The care that will be given to subjects who receive placebo. If this is local standard of care, 
specify that.  
Local standard of care plus more detailed information about healthy eating and exercise from 
study staff at the time of the visits or via electronic communication. 
o All potential risks to the placebo group and how the risks will be minimized. NA 
• 
Provide a description of all research procedures being performed as follows: 
o How individuals will be screened for eligibility. Specify screening that will take place prior to 
informed consent and screening that will take place after informed consent.  
Screening before consent will be performed by a review of the delivery logs on Labor and 
Delivery on a daily basis using the screening log form. Contact information with be obtained and 
the subjects who express interest before their postpartum visit will be met by study staff to review 
in detail the study objectives, protocol and procedures.  
o Procedures being performed to monitor subjects for safety or to minimize risks. 
Study subjects in the intervention arm will have frequent contact with lifestyle trainers and 
nutritionists initially approximately 3 times/week, then approximately 2 times, then 
approximately one time per week in person. Assuming the subject is maintaining her weight 
contact will then be continued with frequent phone calls and via email, text or downloading of 
data from Fit Bit.  
o All drugs and devices used in the research, their regulatory approval status, and the purpose of 
their use. NA 
o The source records that will be used to collect data about subjects. (Attach all surveys, scripts, 
and data collection forms.) 
Please see attached documents. 
• 
Describe the following concerning pregnancy testing and birth control: 
o Whether pregnancy testing will be conducted on women of reproductive potential?  If testing 
will not be conducted, provide the reason.  
Pregnancy testing will be determined on all pregnant women at the time of metabolic visits. 
Additionally, a POC test will be performed by LIPP staff when a VO2max test is done outside of 
the metabolic visit. We will not do pregnancy testing once the subjects enter the pregnancy 
component of the study. 
o What birth control methods women of reproductive potential will be instructed to use. If women 
will not be instructed about acceptable methods of birth control, clarify why.  
Subjects are instructed to use birth control for at least 7 months post-delivery. The choice of 
birth control will be noted but the choice will be up to the subject and her medical provider. 
o What birth control methods men of reproductive potential will be instructed to use. If men will 
not be instructed about acceptable methods of birth control, clarify why. NA 
• 
Specify which procedures, tests, visits, etc. described above are part of usual standard of care at Tufts 
and which are performed solely for research purposes. All the studies obtained as part of the protocol 
are for research purposes.  
Subjects will be given a copy of their results to share with their health care provider. 
• 
Clarify which tests are routinely performed for clinical care, but are providing data for the research, 
and which tests are only performed for research purposes. 
Yes
No

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None of the testing performed as part of the protocol is for clinical purposes. Subjects are free to 
share the information, for example, the results of the OGTT, with their health care provider. 
 
5.3 Evaluations 
Will you perform any laboratory tests for this study?  
  
If Yes, describe the following: 
• 
List all laboratory tests to be done as part of the study (e.g., hematology, clinical chemistry, 
urinalysis, pregnancy testing).  
CBC without differential, urine pregnancy test, HbA1c, Lipid profile, Basic metabolic panel, Liver 
panel, TSH, urine urea nitrogen. The OGTT will be performed to measure insulin sensitivity and beta 
cell response.  
• 
Differentiate screening laboratory test(s) from those taken after enrollment.  
o List special assays or procedures required to determine study eligibility or assess the effect of 
the intervention (e.g., immunology assays, pharmacokinetic studies, images, flow cytometry 
assays, microarray, DNA sequencing). For research laboratory assays, include specific 
assays, estimated volume and type of specimen needed for each test. For procedures, provide 
special instructions or precautions. The above are the screening laboratory tests. If the 
subject has diabetes, hypertension, hyperthyroidism etc. she will be ruled out based on 
exclusion criteria. The special assays listed above are  
NA 
• 
Include specific test components and estimated volume and type of specimens needed for each test.  
The initial visit will obtain a total of ~91cc (baseline eligibility labs plus OGTT). Subsequent visits 
will obtain ~83cc only for the OGTT component of the study. When there is lack of funding, 
subsequent pre-pregnancy visits will only obtain ~49cc of blood for the OGTT and pregnancy 
metabolic visits will obtain ~25cc for a fasting blood sample. Blood collection procedures may revert 
to those previously-approved if additional funding is secured. 
• 
Specify laboratory methods to provide for appropriate longitudinal and cross-sectional comparison 
(e.g., use of consistent laboratory method throughout study, use of single, central laboratory for 
multi-site studies).  
The glucose from the OGTTs will be obtained real-time onsite or in the MIRI lab. The estimated 
intra-assay coefficient of variation is ~ 2%. The rest of the laboratory studies will be batched so that 
each subject’s complete analysis is obtained at one time. The intra-assay coefficient of variation 
varies depending on the test but is generally less than 5% and the inter-assay coefficient of variation 
is generally less than 10%. 
• 
If more than one laboratory will be used to perform study tests, specify which evaluations will be 
done by each laboratory.  
The Tufts Medical Center and Brigham & Women’s Hospital labs will perform the routine laboratory 
studies at the 3-month postpartum metabolic visit. A urine pregnancy test as a POC test will be 
performed before each metabolic visit, except the pregnancy visits; additionally, a urine pregnancy 
POC test will be performed by LIPP staff when a VO2max test is done outside of the metabolic visit. 
The glucose and cytokine measures will be performed in the Maternal Infant Research Institute 
(MIRI) and BWH Research Facility, and the insulin and enteroinsular axis response will performed at 
the Pennington Biomedical Research Institute.  
• 
Specify if the laboratory tests that will be performed are in compliance with Clinical Laboratory 
Improvement Amendments (CLIA) of 1988. If not, explain why.  
All laboratory tests performed in the TMC and BWH hospital laboratories will be performed in 
compliance with Clinical Laboratory Improvement Amendments (CLIA) of 1988. The studies 
performed in the MIRI and PBRC will be performed for research purposes only. 
• 
If samples will be stored for the purpose of this study, describe the preparation, handling, and 
storage of specimens, including specific time requirements for processing, required temperatures, 
Yes
No

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aliquots of specimens, where they will be stored, how they will be labeled, and what will happen to 
the samples after the study is over (e.g. will be destroyed).  
Samples from CTRC or the HNRCA will be placed on ice and then brought to the MIRI during the 3 
hour OGTT or fasting blood draw, or processed on site.  Samples will be aliquoted in separate vials in 
the MIRI to avoid freeze thaw cycles. Samples will be bar coded using a unique identifier code for 
subject name and study visit. Samples not run real time, will be stored in -80°Cfreezers in the MIRI. 
Samples not used at the completion of the study will be destroyed. The cord blood samples at the time 
of delivery will be brought to the MIRI for processing (glucose), and then aliquots stored at -80°C for 
analysis of insulin, cytokines and lipids. Samples from the BWH Research Facility will be handled in 
a similar manner but in the BWH research lab. 
The placentas obtained at the time of delivery will be fixed for histological analysis, submerged in 
RNA Later, or snap frozen in liquid nitrogen and stored at -80°C for molecular analysis. For a subset 
of the subjects, we will obtain fresh placental tissue for lipid metabolism activity assays. 
After participants have completed the study, insulin, c-peptide, and incretin samples will be sent to 
the PBRC site for analysis. Similarly, inflammatory markers, other biomarkers as noted and placental 
samples, will be shipped to TMC or BWH for analysis. An MTA will be obtained from the respective 
sites prior to shipping. 
 
5.4 Collection and Storage of Human Biological Specimens (Tissue Banking) 
Will biological specimens be stored for future, unspecified, research?   
Yes, please see Form 6 and attached letter. 
x
  
 
6 
Ethics and Protection of Human Subjects 
6.1 Informed Consent Process 
Will subjects be required to provide informed consent? 
  
If Yes, describe the following: 
• 
Where the consent process will take place (e.g. a private clinic room.) 
Informed consent will take place at the postpartum visit or at the time of the 3-month postpartum 
metabolic visit before testing. 
• 
Anticipated amount of time a potential subject will have to make a decision about participation in the 
study.  
Three calendar months. 
• 
Processes to ensure ongoing consent throughout the study.   
Frequent visits and contacts and the ability to take the consent form home before needing to sign consent 
at or prior to the baseline visit. In addition to the re-consent process, participants will be asked to provide 
verbal consent at the beginning of their early pregnancy visit (12-16 weeks gestation). Verbal consent for 
neonatal measures will also be collected after participants deliver. 
• 
State if you will follow “SOP: Informed Consent Process for Research (HRP-090)”.  
We will follow the SOP: Informed Consent Process for Research (HRP-090)”. 
• 
Non-English Speaking Subjects NA 
o Describe the consent procedures that will be used to enroll non-English speakers (for example, 
the use of IRB approved Short Forms per the IRB’s Short Form policy). If IRB approved Short 
Forms will not be used describe who will conduct the consent interview, use of interpreters, use 
of IRB approved translated documents, etc. 
o If non-English speakers are being excluded, provide the ethical and scientific justification, 
including whether this would be equitable. For example, if non-English speakers are eligible 
for the study and could potentially benefit from participation, it would not be equitable to 
exclude them. 
Yes
Yes
No

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The study is very detailed and involves 1-2 years of participation in the program. If we are able to 
hire a research coordinator who is proficient in a language other than English we will consider 
recruiting non-English speakers. We will consider the use of interpreters for non-English speakers 
after the study is up and running at TMC/HNRCA and BWH.  
 
Refer to the IRB Short Form Policy on the IRB website for information on enrolling non-English 
speakers. 
  
• 
Process to Document Consent in Writing 
o State if you will follow “SOP: Written Documentation of Consent (HRP-091)”. If not, describe 
how consent will be documented in writing.   
We will follow the SOP: Written Documentation of Consent (HRP-091) 
o If you will obtain consent, but will not document consent in writing, attach a consent script and 
confirm the following (you may use Tufts IRB ICF templates to create the consent document or 
script): NA 
 
6.2 Waiver or Alteration of Consent Process 
This applies for studies where informed consent will not be obtained, required information will not be 
disclosed, or the research involves deception. NA 
• 
Is a waiver or alteration of the consent process being requested for this study?  
  
• 
Is a waiver of the consent process being requested for parents for research involving children?  
 
  
• 
Is a waiver of the consent process for planned emergency research being requested?  
  
 
6.3 International Research 
• 
Refer to the IRB’s International Checklist and International Guidance to ensure that all relevant 
information described in those documents is included in this protocol. NA 
 
6.4 Confidentiality 
• 
Describe the procedures in place to maintain confidentiality as follows: 
o Where and how data or specimens will be stored. 
o The hard copy of the information on the study record and the ICF will be stored in a locked 
cabinet in a locked room. The electronic version of the data will be stored in REDCap. 
Information that will be downloaded for analysis will be de-identified first. A copy of the ICF 
will be given to each subject and a copy retained in the subject’s medical record. BMC, MGH 
& BWH will operate in a similar manner with all collected participant information being stored 
in a locked cabinet in a locked room. Transfer of interested parties contact information will 
occur via secure email or a secure Mass General Brigham maintained Dropbox. 
▪ 
Specifically, state where the study records, including both electronic and/or paper study 
documents including signed ICFs/assent forms, will be retained (stored) during the study 
(state the location for original document plus any copies that are made, e.g., if a copy of 
the ICF will be retained in the subject’s medical record).  
o How long the data or specimens will be stored.  
Until the completion of the study and data analysis is complete. 
o Who will have access to the data or specimens?  
Only study-wide LIPP, BWH Research Facility, CTRC, HNRCA or MIRI laboratory staff 
Yes
No
Yes
No
Yes
No

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o Who is responsible for receipt or transmission of the data or specimens locally?  
LIPP study staff who are members of the MIRI (P Catalano, P O’Tierney-Ginn and study 
coordinator Li Yin Cheok) and BWH Research Facility. The minimum amount of information 
required for scheduling will be shared with laboratory or university staff that are involved in 
study visits. Data and specimens will be in a coded data set using a unique LIPP study code 
number. Physiological data will be sent via the BWH Research Facility, HNRCA or CTRC 
staff.  
o How data and specimens will be transported.  
BWH Research Facility, HNRCA or MIRI LIPP study staff will transport specimens. Data and 
specimens will be de-identified using a unique LIPP study code number. 
o Whether data will be coded.  
Yes we will use bar code identification 
▪ 
If so, specify if there is a key to the code that matches the subjects’ study identification 
number with their name and who will have access to it. 
Any key to bar code information will be kept in the LIPP research study coordinator’s 
office  
o Whether videotapes and/or photographs of subjects will be capable of identifying the study 
subject. If so, indicate who will have access to (be able to view) these items and how long the 
videotapes or photographs will be retained for the study and what the plan is for their 
destruction. NA 
o If identifiable screening data will be retained for the study, clarify why, and who will have 
access to it.  Submit the screening log.  
Screening log has been submitted.  Access will be through the LIPP research study coordinator 
and/or PI.  
It will be necessary to include HIPAA data on the screening log so that when approaching the 
potential subject postpartum one can refer to specific inclusion and exclusion criteria. Further, 
the screening log will be used as a contact source for the patient at the time of the postpartum 
visit and in order to contact via email or text message. 
We have been very careful about ensuring privacy of study subjects whether screened or 
enrolled in our studies. The paper versions of the screening log will be maintained in a locked 
room in a locked file cabinet. The electronic version will be kept on a Tufts Medical Center 
server in a secure data file. Once the data is entered onto the REDCap database maintained by 
LIPP study staff at PBRC, the information will be de-identified and use only a secure unique 
study number. 
o Clarify whether confidential genetic information will be collected from subjects. NA 
Data and specimens should be stored in a secure location only accessible by the research team. 
The PI must ensure that study documents are stored in a manner that protects the privacy of 
subjects and the confidentiality of study data. 
• 
Indicate whether a Certificate of Confidentiality will be obtained. A Certificate of Confidentiality 
should be obtained for research involving collection of information that, if disclosed, could have 
adverse consequences for subjects or damage their financial standing, employability, insurability, or 
reputation. For more information, refer to NIH’s Certificates of Confidentiality Kiosk. NA 
 
6.5 Provisions to Protect the Privacy Interests of Subjects 
• 
Describe the steps that will be taken to protect subjects’ privacy interests. “Privacy interest” refers to 
a person’s desire to place limits on with whom they interact or to whom they provide personal 
information.  
Personal information will only be available to LIPP, BWH Research Facility, MIRI, CTRC and 
HNRCA study staff. All other information will be de-identified for example for statistical analysis or 
DSMB review.   

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• 
Describe the steps that will be taken to make the subjects feel at ease with the research situation in 
terms of the questions being asked and the procedures being performed. “At ease” does not refer to 
physical discomfort, but the sense of intrusiveness a subject may or may not experience in response to 
questions, examinations, and procedures.  
The consent form will describe the study procedures in detail. The study protocol will be explained to 
the subjects as well. At the time of the visit, the LIPP study staff (PI when available and study 
coordinator) in addition to the CTRC, HNRCA or BWH Research Facility staff will be present to 
answer any ongoing questions. For those subjects randomized to the intervention group, HNRCA or 
BWH Research Facility staff will be present during the visit as well as the training sessions. Hence, 
there will be continuity of staff with all subjects in the LIPP study. 
• 
Under what circumstances will the research team access sources of information about the subjects. 
The only time the LIPP research team will access sources of information about potential subjects is 
when the postpartum delivery records are screened for subject eligibility and the outcome pregnancy 
and delivery. 
 
6.6 Provisions to Monitor the Study to Ensure the Safety of Subjects 
• 
Describe the plan to periodically evaluate the data regarding both harms and benefits to assess 
subject safety as follows: We will continue to have a DSMB to evaluate subject benefit and harm. 
o Study data, including safety data, untoward events, and efficacy data, will be reviewed on a 
regular basis. 
Please refer to the DSMB charter. 
o Who will review the data?  
The DSMB this will include representatives from Case Western Reserve in Cleveland, TMC in 
Boston and PBRC in Baton Rouge. This has been made available to the IRB 
o How the safety information will be obtained and documented (e.g., case report forms, by 
telephone calls with participants, printouts of laboratory results, etc.). 
Per the format laid out in the DSMB which was in place in Cleveland. 
o The frequency of data collection, including when safety data collection starts.  
Safety collection starts when the first subject is enrolled into the study, in particular for the 
intervention group starting training. 
o The frequency or periodicity of review of cumulative data.  
This will depend on how there is progression of recruitment. In Cleveland we had a DSMB 
approximately twice in the first year of the grant. We will have a minimal of 1 DSMB meeting 
per year. 
o The statistical tests for analyzing the safety data to determine whether harm is occurring. 
The LIPP study statistician who will be located at Pennington Biomedical in Baton Rouge will 
determine this.  
o Any conditions that trigger an immediate suspension of the research or other action for the 
research.  
Any severe adverse reaction will trigger a review and determination if this was related to the 
research protocol.  
o The plan might include establishing a data monitoring committee which addresses all the above.  
• 
Describe the entity responsible for monitoring the data, and their respective roles (e.g., the 
investigators, the research sponsor, a coordinating or statistical center, an independent medical 
monitor, a Data and Safety Monitoring Board (DSMB) /Data Monitoring Committee (DMC), and/or 
some other entity, and the timeframe for reporting events to this entity.   
o Submit a copy of the DSMB/DMC Charter if the study is monitored by a DSMB/DMC.  
We have submitted the DSMB Charter for the LIPP study in Cleveland as well as the two 
DSMB reports (both open and closed) to the Tufts Medical Center IRB. 
 

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6.7 Compensation for Research-Related Injury 
Does the research involve greater than minimal risk to subjects? (Alternatively, if minimal risk, is there 
potential risk of research-related injury?): 
  
If Yes, describe the available compensation in the event of research related injury including: 
• 
What this compensation will be (e.g. free medical care, payment for treatment, compensation for lost 
wages, dependent care, etc.).  
There is the potential for risk to the subjects in the intervention group, sprains and fatigue after 
exercise. These have not been of any severe degree to affect study participation based on the first year 
of experience in Cleveland. There will be no compensation for any injury or loss of employment. 
• 
Who will provide this compensation (e.g. sponsor, institution, etc.)? NA 
• 
What will count as a qualified harm (e.g., physical, psychological, economic, social, or other injury)? 
Qualified harm will be determined by a serious adverse event related to the study protocol as 
determined by the DSMB 
• 
Whether only injuries “related” to study, participation will be covered.  If yes, clarify how it will be 
determined what injuries are considered related, and who will decide this.    NA 
• 
Will the study distinguish between injury (short-term, resolvable) and impairment (often longer-term, 
potentially manageable, but not resolvable) and if so, why. NA 
• 
The process subjects must follow to obtain compensation. If no funds are set aside for research-
related injury and subjects and/or their insurance will have to pay for the treatment of such injuries, 
include a statement such as: “No funds have been set aside for research-related injury. You or your 
insurance carrier will be required to pay for medical care associated with your research-related 
injury.” 
This has been similar to the language in all of our previous consent forms. 
“No funds have been set aside for research-related injury. You or your insurance carrier will be 
required to pay for medical care associated with your research-related injury.” 
 
6.8 Economic Burden to Subjects 
Does the research involve any costs to subjects? 
  
 
6.10 Vulnerable Populations 
If the research involves individuals who are vulnerable to coercion or undue influence, describe the 
rationale for their inclusion and the additional safeguards included to protect their rights and welfare. 
Will pregnant women be enrolled?   
  
If Yes, describe the following: 
• 
Any preclinical studies, including studies on pregnant animals, and clinical studies, including studies 
on non-pregnant women, that have been conducted that provide data for assessing potential risks to 
pregnant women and fetuses.  
The preliminary data that was obtained in Cleveland was data that included the number of women 
who might be eligible based on inclusion and exclusion criteria. The other preliminary data was the 
review of the average time to the second pregnancy. None of these information provided data related 
to risk to subjects relative to intervention. 
• 
Whether the risk to the fetus is caused solely by interventions or procedures that hold out the prospect 
of direct benefit for the woman or the fetus or if there is no prospect of benefit to the fetus, the risk to 
the fetus is NOT greater than Minimal Risk, and the purpose of the research is the development of 
important biomedical knowledge which cannot be obtained by any other means. 
Yes
No
Yes
No
Yes
No

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There is no risk to the fetus from participation in the study. The ACOG recommends that pregnant 
women partake in physical activity during pregnancy for 30 min at least 5 days a week. Our study 
protocol recommends that all subjects follow ACOG guidelines for diet and physical activity and gain 
weight according to IOM recommendations from 2009. 
• 
The biomedical knowledge that is expected to result from this research for this population. 
Importance of the Knowledge Gained 
The importance of the knowledge to be gained by this proposal is the ability to determine if Lifestyle 
Interventions in Preparation for Pregnancy can achieve concrete (real) results in the efforts to stem the 
epidemic of obesity in women and their offspring. This study will also provide information as to the 
mechanisms of why lifestyle intervention before rather than only during pregnancy results in 
improved outcomes. Although the concept of pre-pregnancy lifestyle intervention has been 
recognized previously as potentially worthwhile, there have been few if any studies employing such a 
study design, because of the perceived difficulty in recruiting women prior to pregnancy. Based on 
our history of conducting research studies in women before during and after pregnancy, a study 
design of recruiting obese women immediately after pregnancy and incorporating the community into 
the lifestyle interventions, we believe that this approach will have applicability in many other 
populations. 
The risks to subjects are minimal. They are the standard of care we should provide to all our obese 
patients considering future pregnancy. Our ability to provide more than a minimal amount of 
information is hampered by the lack of resources particularly for women seeking care without 
considerable personal resources. If successful, as proof of principle, we believe this protocol can 
serve as a paradigm for a wider initiation of lifestyle interventions before pregnancy. 
• 
How any risk of this research is the least possible for achieving the objectives of the research? 
Risk will be minimized by having trained lifestyle intervention staff supervise physical activity and 
nutritionist the healthy eating for the Intervention group. The usual care group will receive benefit 
from having specific goals provided by our research team but not specific follow-up per the study 
protocol. 
• 
How mothers providing consent are informed of the reasonably foreseeable impact of the research on 
the fetus or neonate.  
Mothers are informed by the PI of the study and potential benefits of healthy eating and exercise 
before pregnancy. They will also be informed of the foreseeable impact of the research on their 
fetus/neonate. 
• 
Specify that no inducements, monetary or otherwise, will be offered to terminate a pregnancy and 
that in the case of a fetus, the fetus is not the subject of a planned abortion. NA 
• 
Specify that individuals engaged in the research will have no part in any decisions as to the timing, 
method, or procedures used to terminate a pregnancy or in determining the viability of a neonate. NA 
 
Will the research involve neonates of uncertain viability or non-viable neonates?  
  
 
Will subjects who are not yet adults (neonates, children, teenagers) be enrolled?  
 Neonates will be included in the study as an outcome measure. 
a. 
 Check to confirm that you will follow “SOP: Legally Authorized Representatives, Children, and 
Guardians (HRP-013)” to determine whether a prospective subject has or has not attained the legal 
age for consent to treatments or procedures involved in the research under the applicable law of the 
jurisdiction in which the research will be conducted. (e.g., individuals under the age of 18 years).   
If this SOP will not be followed, describe how this (attainment of legal age for consent or not) will be 
determined:        
b. How permission to participate in the study will be obtained from the parents or legal guardians: See 
Informed Consent section above.  Permission will be obtained from parents or legal guardians as 
described in that section.  
Yes
No

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c. The assent process of children as follows: 
i. 
Any waiting period available between informing the prospective subject and obtaining the 
assent: N/A 
ii. 
Any process to ensure ongoing assent: N/A 
iii. 
Research team members involved in the assent process: N/A 
iv. 
How long children will have to consider study participation: N/A  
v. 
Steps that will be taken to minimize the possibility of coercion or undue influence: N/A 
vi. 
Steps that will be taken to ensure the subjects’ understanding: N/A 
vii. 
If assent will not be obtained from children, specify why: All children enrolled will be infants 
without the capacity to provide informed assent. 
viii. 
If children reach 18 years of age while in the study describe the following: 
1. The plan to obtain written informed consent from the subject at age 18 years: N/A 
2. Who will be responsible for managing the plan: N/A 
3. Where the consent discussion will take place: N/A 
4. What will happen if the subject cannot be located to provide consent at age 18 years: N/A 
 
Will minors under the age of 18 who are:  
i) 
married, widowed, divorced; or  
ii) 
the parent of a child; or  
iii) 
a member of any of the armed forces; or  
iv) 
pregnant or believes herself to be pregnant; or  
v) 
living separate and apart from his/her parent or legal guardian, and is managing his/her own 
financial affairs  
Be approached for study participation for either themselves or their child?  
 
  
Will wards of the state and/or children at risk of becoming wards of the state be enrolled (this includes 
foster children or any child that is in state custody)?            
 
  
 
Will cognitively impaired adults (adults with impaired-decision making capacity) or adults who may lose 
the capacity to consent be enrolled?  
  
 
Will prisoners be enrolled?  
  
Will students and/or employees be enrolled in this research?  
 
 
If Yes, describe the following: 
• 
Justification for specifically recruiting and enrolling students and/or employees into the study. 
Women who are overweight or obese delivering babies at TMC will be given the opportunity to enroll 
like any other subject who meets inclusion criteria. 
• 
How potential coercion will be eliminated.  
By strictly following inclusion and exclusion guidelines. 
• 
Recruitment methods to be applied specifically to students or employees. If the same recruitment 
methods previously described in the protocol will be used, then state that.  
N/A, The same criteria used for recruitment will apply to all potential subjects. No specific 
recruitment aimed at employees 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

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• 
Additional safeguards included to protect the rights and welfare of students and employees.  
No other than has already been described. 
• 
Protections to ensure that a subject’s participation or early withdrawal from the study will not affect 
his/her status as a student or employee. Per the statements in the approved subject consent form  
• 
Submit a letter from the appropriate institutional official (e.g., Department Chair, Vice-President) 
who oversees the students and/or employees attesting to the fact that the employee or student’s 
participation in the research is acceptable and that coercion has been minimized. 
 
7 
Adverse Event Monitoring 
7.1 Definitions 
• 
Define adverse events (AEs), serious adverse events (SAEs), and unanticipated problems for your 
study. 
Please refer to the DSMB definitions 
During the course of the LIPP study, all adverse events (AEs) and serious adverse events (SAEs) will 
be monitored, documented, and if causal reported to BWH, TMC and the PBRC and the Data Safety Monitoring 
Board (DSMB). The Chair of the DSMB will be located at the PBRC. Every attempt will be made to follow a 
subject who has had negative reaction to any study intervention or procedure. 
 
General Reporting Guidelines 
Adverse Events (AEs) 
 
An Adverse Event (AE) is any unfavorable medical occurrence, which may include abnormal signs (for 
example, abnormal physical exam or laboratory finding), symptoms, or disease, temporally associated with, but 
not necessarily considered related to, the subject's participation in the LIPP research study.  These events are 
usually of a non-serious nature and are not reportable in accordance with the Institutional Review Board 
guidelines of the respective hospitals/ Universities for "Reportable Events," as they do not pose risk to study 
subjects. 
Adverse events that take place during the course of the LIPP study will be classified under the 
Common Terminology Criteria for Adverse Events (CTCAE), a descriptive terminology used for Adverse 
Event (AE) reporting.  AEs will be categorized as expected or unexpected in terms of their nature, severity, or 
frequency as outlined in the consent form.  AEs will be graded using the CTCAE system and relatedness 
assessed by the PI and presented to the DSMB at DSMB meetings. 
 
Serious Adverse Events (SAEs) 
 
Serious Adverse Events (SAEs) or "Unanticipated Problems Involving Risk to Subjects or Others," are 
characterized as symptoms which are harmful to the subject and result in significant outcomes which are 
reportable to the respective IRBs and the study's DSMB. 
 
Examples of serious adverse events are: 
 
▪ 
Death 
▪ 
Life threatening medical events that place a subject at immediate risk of death from the event as it occurred 
▪ 
Results in impatient hospitalization or prolongation of existing hospitalization 
▪ 
Results in persistent or significant disability or incapacity as a result of the study intervention 
▪ 
Events that, based upon appropriate medical judgment, may jeopardize the subject's health and may require 
medical or surgical intervention to prevent one of the other outcomes listed in this definition. 
 
The flow chart below provides an algorithm for determining whether an adverse event meets the definition of an 
"unanticipated problem involving risk to subjects or others." 
 
                                                  An adverse event occurs  

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in one or more subjects. 
 
 
 
 
 
Is the adverse event unexpected in nature,  
severity, or frequency? 
 
  
 
 
 
 
Is the adverse even related or possibly related           
to participation in the research?  
 
 
 
 
 
 
Does the adverse event suggest that the research 
places subjects or others at a greater risk of  
physical or psychological harm than was  
 
previously known or recognized? NOTE: If the 
adverse Event is serious the answer is always yes. 
 
 
 
  
 
      Report the adverse  
The adverse event is not 
      event as an 
 
an unanticipated problem 
      unanticipated problem  
 
and need not be reported 
      under 45 CFR part 46 
 
under 45 CFR part 46. 
 
 
 
 
 
 
Adverse Events which follow the above figure, that meet the criteria of unexpected, fatal or life- 
threatening, and related or possibly related to the research intervention must be reported to the IRB and the 
DSMB within 24 hours of learning of the event.  If necessary, a subsequent follow-up report with the details of 
the event will be submitted as well. All other reportable adverse events will be submitted to the IRB within 10 
working days of the investigator learning of the event.  Reportable events will be submitted through the respective 
IRB's system.   
 
AE and SAE Assessment Guidelines Specific to the LIPP Study  
 
Key Criteria: to determine if the event is unexpected, related to participation in the research study and involves 
risk to human subjects or others. 
 
If an adverse event meets the criterion of unexpected, related or possibly related, and poses risk of harm to other 
subjects, the study coordinator will notify one of the Multiple Principal Investigators, Dr. Patrick Catalano or 
Dr. John Kirwan, within 24- hours who will then inform the DSMB Chair and the Tufts Health Sciences IRB; 
the reviewing IRB of record. 
 
To evaluate AEs and SAEs, a licensed medical professional will apply the following assessment criteria: 
Event Expectedness 
Unexpected Medical Events: 
These are the medical events that are not described in the current IRB-approved protocol or informed consent, 
taking into account the characteristics of the participant population being studied (e.g. pregnant population). 
Expected medical events*: 
NO 
NO
NO 
YES 
YES 
YES
YES 

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▪ 
Symptoms and risk related to normal pregnancy progression such as nausea, vomiting, fatigue, urinary 
frequency, increased or decreased appetite, transient dizziness, mild back or breast pain or discomfort, 
mild mood changes, miscarriage, preterm delivery, still birth, low birth weight, problems with placenta 
and birth defects, 
 
▪ 
Symptoms related to fasting for at least 8-hours and related hypoglycemia: headache, nausea, and 
lightheadedness 
▪ 
Symptoms related to hypoglycemia such as fainting, fast heart rate, sweating, shakiness, difficulty paying 
attention, sudden moodiness or irritability, unconscious 
▪ 
Symptoms related to venous blood draw such as bruising, bleeding, swelling, and pain, fainting, 
lightheadedness and infection at the injection site. 
▪ 
Symptoms related to consuming the glucose solution for the diabetes testing such as brief nausea, 
vomiting, tiredness, lightheadedness and upset stomach. 
* While the above medical events may be expected, they will be collected for outcome purposes. 
 
Event Severity using Common Terminology Criteria for Adverse Events (CTCAE) 
Grade refers to the severity of the AE. The CTCAE displays Grades 1 through 5 with unique clinical descriptions 
of severity for each AE based on these general guidelines: 
• 
Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention 
not indicated. 
• 
Grade 2 Moderate; minimal, local or noninvasive intervention indicated limiting age-appropriate 
instrumental activities of daily living. 
• 
Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or 
prolongation of hospitalization indicated; disabling; limiting self-care.  
• 
Grade 4 Life-threatening consequences; urgent intervention indicated. 
• 
Grade 5 Death related to AE. 
 
Event Relatedness 
 
Related: The incident, experience, or outcome is more likely than not caused by study procedures. 
 
• 
A reasonable time course would be within the 1-4 hours the subject is receiving oral glucose tolerance 
testing. 
• 
Symptoms abate once the study product is discontinued and patient has received a snack or drink. 
Symptoms are not explained by other factors such as concomitant medications or current illness 
 
Possibly Related: There is reasonable possibility that the incident, experience or outcome may have been caused 
by study procedures. 
 
• 
A reasonable time course would be within 24-48 hours the subject either fasting for the study or receiving 
the oral glucose tolerance testing. 
 
• 
Symptoms may be explained by other factors such as concomitant medications or current illness 
 
Adverse Event 
VO2 max 
Falling off treadmill    
VO2 max 
Exhaustion 
VO2 max 
Feeling like heart is pounding very fast or 
very hard 

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VO2 max 
Dizziness 
VO2 max 
Heart rhythm abnormalities 
VO2 max 
Chest pain 
VO2 max 
When the mask is on the face, this might 
feel uncomfortable 
Structured exercise 
Feeling like heart is pounding very fast or 
very hard 
Structured exercise 
Dizziness 
Structured exercise 
Heart rhythm abnormalities 
Structured exercise 
Chest pain 
Laboratory studies 
Bruising at IV site 
OGTT 
Nausea from glucose load 
OGTT 
Bruising from IV site 
Resting Metabolic 
Rate 
Claustrophobia  
Bod Pod 
Claustrophobia 
Neonatal 
Anthropometrics 
Bruising from skinfold calipers 
Maternal 
anthropometrics 
Bruising from skinfold calipers 
 
Serious Adverse Event 
VO2 max 
Heart attack 
VO2 max 
Death 
Structured exercise 
Heart attack 
Structured exercise 
Death 
 
 
7.2 Reporting Procedures 
• 
Describe the protocol-specific reporting procedures, including who will be responsible for each step 
(e.g., PI, Data Coordinating Center, Medical Monitor), which forms should be completed, timeframes 
for reporting, how reports will be distributed, and what follow-up is required.  
• 
Include specific details of reporting procedures for: 
o Deaths, life-threatening events, pregnancies PI 
o Other SAEs PI or study coordinator 
o Other AEs study coordinator 
o Other UPs study coordinator 
All the details are noted in the DSMB charter. The reporting mechanisms are noted above, 
since different adverse events are reported based on the degree of severity  
• 
Ensure that the reporting procedures meet the reporting requirements of the FDA, NIH, OHRP, 
sponsor, study leadership and any other regulatory body that applies to the study, as applicable.  
NIH will receive a yearly non-competitive renewal notice of the progress of the study and any serious 
adverse events related to the study protocol. 

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7.3 Reportable New Information 
• 
Indicate also, that reportable new information will be reported to the IRB per the Tufts Health 
Sciences IRB’s Reportable New Information policy. If your reporting plan to the IRB differs from the 
IRB’s policies, please describe it in detail. NA 
Reportable new information will be reported to the IRB per the Tufts Health Sciences IRB’s 
Reportable New Information Policy 
 
8 
Statistical Considerations 
8.1 Study Endpoints 
• 
Describe the primary and secondary study endpoints.  
The primary outcome measure of this proposal is lower neonatal adiposity at birth in the LIPP group 
relative to: 1) the usual care/control group. As secondary outcomes we anticipate that prior to a 
subsequent pregnancy, LIPP will produce significant improvement (absolute and percent changes) in 
maternal weight and body composition, and more importantly improved insulin sensitivity, β-cell 
function, incretin response to glucose, lipid and inflammatory biomarkers, compared to the Control 
group. We also expect reduced insulin resistance, umbilical cord lipids and inflammatory profiles in 
babies born to LIPP subjects compared to Controls. 
• 
Describe any primary or secondary safety endpoints.  
The risk of having a small for gestational age baby or preterm delivery will be followed closely in the 
intervention group, as this is a theoretical risk.   
8.2 Statistical Analysis 
• 
Describe the statistical analyses that will be performed for this study 
Statistical Analysis 
The primary analyses of Specific Aim 1a will be intent-to-treat comparisons of the LIPP and 
Control groups in regard to changes in maternal insulin sensitivity, BMI, and fat mass. The 
comparisons will be performed first with two-sample t-tests at α=0.05. Should any imbalance 
of confounding factors in the groups be recognized, linear regression models that include 
significant differences (e.g. GDM) would be used to perform covariate adjustments. Based on 
our 1-year postpartum follow-up studies (62,63), we will have 90% power to detect an 
absolute or covariate-adjusted improvement in insulin sensitivity of 30% and an 80% power 
to detect an improvement as small as 25% in the LIPP vs. Control group. Corresponding 95% 
confidence intervals (95% CI) for the absolute or covariate-adjusted differences or percent 
improvements in insulin sensitivity between groups will be reported. We estimate the 
standard deviation (SD) of change in BMI from randomization until subsequent pregnancy to 
be 5.1 kg/m2. We will have 90% power to detect an absolute or covariate-adjusted difference 
in BMI of 2.6 kg/m2 and 80% power to detect a difference of 2.26 kg/m2 and 90% power to 
detect an absolute or covariate-adjusted difference in fat mass of 5.9 kg and 80% power to 
detect a difference of 5.1 kg between groups prior to the second pregnancy. 
The primary analysis for Specific Aim 1b is an intent-to-treat comparison of LIPP versus 
Control neonates with respect to fat mass at birth. The comparison will be performed using a 
two-sample t-test at α=0.05. Linear regression will be performed, which will include weight 
(body composition measures) of the subject’s index child as a covariate. Should any 
imbalance of confounding factors (for example gestational age) in the groups be recognized, 
linear regression models will be used to perform a covariate adjustment. Based on our 
preliminary data, we estimate the SD of neonatal fat mass between the LIPP and Control 
groups to be no more than 225 g. With at least 50 women in each group, (assuming a 50% 
dropout), the t-test or linear regression will have 90% power to detect an absolute or 
covariate-adjusted difference of 146 g fat mass between groups. We have 80% power to 
detect an absolute or covariate-adjusted difference as small as 126 g fat mass between groups. 
Corresponding 95% CI for the absolute or covariate-adjusted difference in neonatal fat mass 
between groups will be reported.  For secondary analyses, we will be using the same 

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statistical approach. Based on our preliminary data, we estimate the SD of birth weight to be 
700 g; with 50 neonates in each group we will have 90% power to detect an absolute or 
covariate-adjusted difference of 455 g in birth weight and 80% power to detect a 393g 
difference between groups. Additional secondary analyses will include umbilical cord 
cytokines. Comparisons will be performed using a two-sample t-test at a significance level of 
α=0.05; however, Mann-Whitney U tests or log transformations will be employed if data are 
not normally distributed. Linear regression models, including confounding factors, will be 
used to perform covariate adjustments. Based on our published data (80), we estimate the 
standard deviations of umbilical cord IL-6 and CRP to be 3.4 pg/ml and 7,900 ng/ml, 
respectively. With 50 women in each group, we will have 90% power to detect an 
improvement in IL-6 and CRP levels of 50% and 42%, and 80% power to detect an 
improvement of 42% and 36%, respectively. 
 
The primary goal of Aim 2 is to determine the effect of lifestyle intervention prior to 
pregnancy on placental mitochondrial fatty acid oxidation at term. We hypothesize that 
placental β-oxidation will be higher in the LIPP group. We will conduct an intent-to-treat 
analysis using two sample t-test or non-parametric Wilcoxon rank-sum test to assess 
differences between groups. Regression analysis will be used to assess the association of 
placental β-oxidation and enzyme activity with maternal inflammatory cytokine levels and 
insulin resistance in early pregnancy, along with neonatal fat mass with adjustment for 
gestational age and gender. Descriptive statistics, such as mean, median and range will be 
calculated for all variables. Power and sample size analysis based on our preliminary 
mitochondrial β-oxidation data in obese women (38±14 nmol/mg/hr) showed that a sample 
size of N=18/group achieves 80% power to detect a difference of 25% between groups using 
a two-sample t-test with a significance level of 0.05. 
 
• 
Provide a power analysis.  
These are included in the statistical analyses. 
 
8.3 Number of Subjects 
• 
If this is a multicenter study, specify the number of subjects to be enrolled in total across all sites. 
220.  
• 
Specify the number of subjects to be enrolled at the Tufts site. Subjects who sign an ICF are 
considered “enrolled”. For studies that have a separate screening ICF, this number is the number of 
subjects who sign a screening ICF.  100 
o Provide the rationale for enrolling this number of subjects at the Tufts site.  
This is approximately 50% of the study recruitment goals of 200. In addition to the already 
recruited participants in Cleveland and Baton Rouge, the Boston sites anticipate to recruit the 
remaining subjects to meet the goals.  
o Estimate the number of subjects expected to be enrolled at the Tufts site (i.e. sign the screening 
or study ICF) as well as the number needed to complete the study at the Tufts site.  
We anticipate recruiting 100 subjects in the Greater Boston area and expect a 40 to 50% 
dropout for various reasons. 
o If a large number of withdrawals and/or dropouts are expected, explain why. 
It is not unusual for a lifestyle intervention study lasting over a number of years to have a 40% 
dropout rate. This has been addressed in the statistical analysis. 
 
8.4 Data Management 
• 
Describe the data analysis plan, including descriptions of the data.  
This is described in the statistical analysis  
• 
Provide a power analysis.  

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This is included in the statistical analysis. 
• 
Describe the steps that will be taken to secure the data (e.g., training, authorization of access, 
password protection, encryption, physical controls, certificates of confidentiality, and separation of 
identifiers and data) during storage, use, and transmission. 
All research staff for the LIPP grant has undergone CITI training and have research experience. The 
PI of the project has 30 years of clinical research training and has not had any research violations of 
authorization of access, password protection, encryption, physical controls, certificates of 
confidentiality, and separation of identifiers and data during storage, use, and transmission. We 
anticipate that the study coordinator of the LIPP grant will have as a minimum a Bachelor’s degree 
and clinical research experience. 
• 
Describe any procedures that will be used for quality control of collected data. 
The Study coordinator, the PI and Statistical staff will ensure that the data has been collected and 
cleaned appropriately. Any data that is judged to be an outlier will be reassessed going back to the 
original source. In the past we have reanalyzed approximately 10% of data to make sure that results 
are consistent with first time analyses. 
• 
Describe how data and specimens will be handled study-wide: 
o What information will be included in that data or associated with the specimens.  
The non-PHI study subject identifier as well as which visit the data was collected will be noted 
and entered into REDCap. 
o Where and how data or specimens will be stored.  
Data will be stored on REDCap. Hard copies will be maintained in a locked cabinet in a locked 
office of the study coordinator. 
o How long the data or specimens will be stored. 
Until the study is completed. Hard copies will be kept as long as the data are being analyzed. 
Non-PHI data will be stored on an encrypted hard drive. 
o Specify who will have access to the data or specimens.  
The PI, study coordinator and staff in the HNRCA and BWH Research Facility will have access 
to the data. The statistical staff and REDCap team will have access to the non-PHI data. 
o Specify who is responsible for receipt or transmission of the data or specimens.  
The study coordinator and PI. 
o Specify how data and specimens will be transported.  
By research staff from the LIPP, BWH Research Facility, MIRI and HNRCA. 
o Specify the plan for study data retention and storage (accounting for research team turnover). 
The PI will maintain the data along with Dr. Kirwan the MPI at the Pennington.  
 
8.5 Randomization 
Will subjects be randomized?  
  
If Yes, describe the following: 
• 
The randomization procedures, including the ratio of subjects randomized to each study arm.  
Yes through a computer generated randomization stratified for overweight vs. obese and 
breastfeeding status. 
• 
The blinding procedures if the study will be blinded.  
N/A, only the statistician analyzing data will be blinded. 
 
9 
Drugs or Devices 
Will the research involve drugs?   
  
Will the research involve devices?   
  
Yes
No
Yes
No
Yes
No

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10 Study Administration 
10.1 Setting 
• 
Describe the sites or locations where your research team will conduct the research.  
At Tufts Medical Center, HNRCA, MIRI, TMC CTRC, TMC Labor and Delivery and TMC newborn 
nursery. At Brigham & Women’s Hospital, the BWH Research Facility, BWH Labor and Delivery 
and BWH Newborn Nursery. 
• 
If the research will take place at an international site, refer to the International Guidance and 
International Checklist. NA 
• 
Describe the following: 
• 
Where research procedures will be performed.  
At Tufts Medical Center, HNRC, MIRI, TMC Labor and Delivery and TMC newborn nursery. At 
Brigham & Women’s Hospital, the BWH Research Facility, BWH Labor and Delivery and BWH 
Newborn Nursery. 
• 
The composition and involvement of any community advisory board.  
We will consider a community advisory board in Boston. We had such a board as part of the 
LIPP project in Cleveland. 
• 
If a hospital stay will be required solely for research and if so, the expected duration of the 
hospital stays. NA 
• 
If inpatients will be enrolled, clarify if study participation will require an increase in the length 
of hospital stay, and if so, for how long. NA 
• 
For research conducted outside of Tufts and its affiliates: Please refer to section Multi-site 
Research  
o Describe the site-specific regulations/customs affecting the research 
o Describe the site-specific local scientific review and ethical review structure 
and procedures. 
o Describe how the study team is/will become knowledgeable of the local study 
site’s culture, customs, regulations, and society. 
 
10.2 Registration 
• 
Describe the steps the research team will take to ensure that a subject is appropriately enrolled or 
registered in the study prior to receiving any study intervention (e.g. describe and submit any 
protocol eligibility checklist that will be used, specify who on the research team will confirm 
eligibility and that consent was documented, etc.). 
The PI will be responsible to make sure that the subject has a thorough understanding of the research 
and procedure, the goals of the study and how they may be randomized into either study arm, i.e. 
usual care or intervention. The study coordinator will be a Master’s or Bachelor’s level person with 
research experience. They will obtain the written consent. The PI or Co-Investigator will review the 
study with the subject and will be available either in person or via telephone to answer any questions 
a potential subject may have before the subject has any evaluation 
 
10.3 Resources Available 
• 
Specify the role and tasks delegated to each research team member.  
 
Pennington Biomedical Research Center – Research team members will perform analysis of data, and 
interactions with participants during recruitment, evaluation in the clinical research unit, for nutrition, and 
for lifestyle changes. Please see addendum for site specific procedures.  
Massachusetts General Hospital & Brigham and Women’s Hospital-- Potential participants will be 
recruited from eligible women who have delivered infants at MGH and BWH. TMC study staff will reach 
out by email, phone, or mail to women who agree to be contacted at a later date and will offer study 
participation. Consent and all subsequent study procedures will be conducted at Tufts Medical Center or 

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Brigham & Women’s Hospital for those women who elect to participate. Cord blood and placental 
collection will be done according to standard of care at the respective hospitals. BWH or MGH LIPP 
research staff will collect designated tissue specimens from the research participant's hospital. Samples 
will be collected according to protocol, aliquoted and processed as needed and placed on ice or liquid 
nitrogen. The designated samples will either be transported to TMC/MIRI for further processing and 
storage by LIPP staff until analysis or processed and stored at BWH until analysis. Neonatal 
anthropometrics will be performed at the institution by LIPP staff and be used as an alternative measure 
for body fat if a PeaPod is not available. Neonatal anthropometrics may be conducted at the houses of 
LIPP participants with their consent if a participant delivers at a facility other than an approved LIPP 
study site and are unable to travel to BWH, MGH or TMC after delivery. Both anthropometrics and 
PeaPod will be performed otherwise. Additionally, for those participants who deliver at BWH or MGH, 
LIPP research staff will conduct study sample collection according to the site protocol. In addition to 
infant measures and study sample collection, LIPP study staff will conduct maternal questionnaires prior 
to delivery and post-delivery. Before delivery, the Infant Feeding Intention Scale will be conducted; after 
delivery, questionnaires will include the Breast-Feeding Self-efficacy after Delivery, Infant Feeding 
Practices Scale and the Holmes-Rahe Life Stress Inventory.  
 
• 
At Tufts Medical Center;  
Patrick Catalano (PI) will oversee the recruitment, metabolic studies of the mother and her baby and 
data analysis. 
Dr. Michael House (CO-I) will oversee any medical findings that may come up during the course of 
the study as an MD on staff at TMC.  
Study coordinator (Li Yin Cheok) – recruitment and follow up of subjects for appointment and 
coordination of lifestyle trainers and nutritionist at TMC, HNRCA and PBRC. 
• 
HNRCA 
Roger Fielding (CO-I) will oversee metabolic testing of non-pregnant subjects and supervise lifestyle 
trainers and nutrition staff. 
• 
Lifestyle fitness trainer will work with subjects randomized to intervention arm and work with Drs. 
Fielding and Catalano to ensure fidelity to intervention protocol. 
• 
At Brigham & Women’s Hospital; 
Dr. Sarbattama Sen (PI) will oversee the recruitment, metabolic studies of the mother and her baby 
and data analysis. 
Dr. Kieran Reid will oversee metabolic testing of non-pregnant subjects, work with subjects 
randomized to intervention arm and work with Dr. Catalano to ensure fidelity to intervention 
protocol. 
• 
Study coordinator will be responsible for recruitment and follow up of subjects for appointment at 
BWH and MGH. 
• 
Describe the qualifications (e.g., training, experience) of the PI and research team to perform their 
roles. Provide enough information for the IRB to determine the PI and research team are qualified to 
conduct the proposed research. Please refer to the Biographical sketches of Drs. Catalano, Kirwan, 
O’Tierney-Ginn, Fielding and Sen.  
• 
Specify the coverage plan to address any issues (including subject safety issues) that occur while the 
PI is away and/or unavailable.  
The research team member designated to serve, as the acting PI in the PI’s absence should have 
similar training and expertise as the PI.   
Drs. Catalano and Fielding will cross cover for the LIPP subjects at Tufts, MGH and the HNRCA. 
Drs. Catalano and Sen will cross over for the LIPP subjects at BWH. The study coordinator and 
Lifestyle coach will cross cover for each other.  
• 
Describe other resources available to conduct the research, for example: 

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o Feasibility of recruiting the required number of suitable subjects within the proposed 
recruitment period. For example, how many potential subjects do you have access to? What 
percentage of those potential subjects do you anticipate recruiting?  
We will have access to subjects delivering at TMC, approximately 1300/year. To increase the 
likelihood of meeting our recruitment goal, we will also be recruiting at BWH, who see a 
higher volume of deliveries; approximately 9000/yr and 3800/yr, respectively. If recruitment is 
not adequate, we will explore recruiting at the other hospitals in Boston for example, BI 
hospital. 
We are in the process of collecting demographic data from the Tufts delivery charts to 
determine eligibility of patients delivering at TMC.  
o Confirm that the amount of time you will spend on the research is adequate to conduct and 
complete the research.  
The PI has no clinical duties and although budgeted at 20% effort will easily spend 40 to 50% 
effort on the LIPP project. 
Facilities HNRCA, MIRI, TMC, BWH Research Facility 
o Availability of medical or psychological resources that subjects might need TMC 
o Process to ensure the research team members have adequate oversight and are adequately 
trained regarding the protocol, study procedures, and their roles and responsibilities. 
Study staff have met once a week in Cleveland and that will continue at Tufts via telephone and 
Zoom conference with the PBRC and Brigham & Women’s Hospital. 
 
10.4 IRB Review 
• 
Specify that an appropriate IRB registered with the OHRP, will review and approve this study.   
• 
Specify that any amendments to the protocol or informed consent documents will be reviewed and 
approved by the IRB prior to use, unless required to eliminate an apparent immediate hazard to 
subjects.    
We have developed a DSMB to oversee the LIPP study.  
We confirm that any amendments to the protocol or informed consent documents will be reviewed 
and approved by the IRB prior to use, unless required to eliminate an apparent immediate hazard to 
subjects.    
 
10.5 Multi-Site Research 
Is this a multi-site study where Tufts is the sponsor, primary grant recipient, or coordinating site? 
  
If Yes: 
• 
Describe the processes to ensure pertinent and timely communication among sites, including: 
o When and how sites will be provided with the current version of the protocol, informed consent 
form, and other study documents.  
When the IRB has approved the protocol and ICF this will be provided to LIPP study staff at 
the PBRC and BWH. The HNRCA site is functionally part of Tufts and any IRB approval for 
the HNRCA will go through the primary site at the MIRI. 
o That all required approvals will be obtained at each site (including approval by the site’s IRB 
of record).  
This will be done before recruitment at the PBRC. At the Pennington, BWH and Tufts sites, we 
will recruit and follow the same protocol at each site. 
o How all modifications will be communicated to sites, and will be reviewed and approved 
(including approval by the site’s IRB of record) before the modification is implemented. 
We continue to have biweekly phone conference calls with staff at TMC, BWH and the 
Pennington. This is currently ongoing and will continue once we have IRB approval from 
TMC. 
Yes
No

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o That all participating sites will safeguard data as required by local information security 
policies.  
The PIs (Catalano and Kirwan) have worked collaboratively not only on the LIPP project but 
also for a number of years. They have multiple projects and manuscripts where they have been 
co-investigators. Both are experienced and have excellent records regarding patient safety and 
data integrity.   
o Assurance that all local site investigators will conduct the study appropriately.  
The PIs (Catalano and Kirwan) have worked collaboratively not only on the LIPP project but 
also for a number of years. They have multiple projects and manuscripts where they have been 
co-investigators. Both are experienced and have excellent records regarding patient safety and 
data integrity. The training for study staff at the Pennington has been completed as they have 
relocated to Baton Rouge with Dr. Kirwan. At BWH, Dr. Sen will ensure that all procedures 
will be conducted according to the study protocol. At Tufts and MGH, the study coordinator 
will work with the PI and Co-I regarding the study recruitment and protocol. We have a weekly 
telephone conference to review procedures etc. 
o That all non-compliance with the study protocol or other reportable new information will be 
reported in accordance with local policy.  
The PI confirms that all non-compliance with the study protocol or other reportable new 
information will be reported in accordance with local policy. 
• 
Describe the method for communicating the following information to participating sites: 
o Problems – Weekly telephone conference calls. 
o Interim results at quarterly meetings.  
o Study closure at the time that data is analyzed and secondary analyses identified. 
o Amendments as the situations demand amendments will be made.  
Any changes to the protocol will be made at both sites and discussed at the weekly telephone 
conference. 
o Research related communications at weekly LIPP conference calls.  
• 
Specify which site is the Data Coordinating Center.  
The Pennington 
• 
Specify if Tufts’ data will be shared outside of Tufts (e.g., with other investigators, sponsor, etc.) and 
how data will be shared.  
Data will be shared with the Pennington on an ongoing basis. At the completion and publication of 
the study, data will be made available to other investigators per NIH guidelines. 
• 
Describe any collaborations not described above, such as: 
o Tufts investigators with multiple affiliations that would engage other institutions in research 
(e.g., Tufts making direct payment to another institution for the research, the research is being 
conducted on behalf of another institution).  
The PI has a bioscientific appointment (no salary) at MetroHealth Medical Center in Cleveland. 
The LIPP grant has transferred to Tufts and Tufts will be the coordinating center for the LIPP 
grant, Dr. Catalano has percent effort on other NIH grants at Tufts as well as at other 
institutions. His percent effort is covered through research administration  
o Each participating site will complete a Form 5 (continuing review form). The Tufts PI will 
collect and submit these to the Tufts Health Sciences IRB for the 2 external relying sites.  
o Each participating site will complete and submit the self-audit tools to the Tufts PI, a summary 
of which will be submitted to the Tufts Health Sciences IRB at the time of continuing review 
(summary of any issues identified during the self-audit). This summary can be described in the 
cover letter accompanying the continuing review application.  The original self-audit checklists 
will be available to the Tufts Health Sciences IRB upon request: 
o File Review Checklist 
o Participant File Checklist 
 

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10.6 Community-Based Participatory Research 
Note: “Community-based Participatory Research” is a collaborative approach to research that equitably 
involves all partners in the research process and recognizes the unique strengths that each brings. 
Community-based Participatory Research begins with a research topic of importance to the community, 
has the aim of combining knowledge with action and achieving social change to improve health outcomes 
and eliminate health disparities. 
Will this study involve community-based participatory research?   
Not at this time, possibly at a later date 
  
 
10.7 Sharing Results with Subjects  
Will results (overall study results or individual subject results, such as results of investigational diagnostic 
tests, genetic tests, or incidental findings) be shared with subjects or others (e.g., the subject’s primary 
care physician or the subject’s treating physician)?   
  
If Yes, describe the following: 
• 
Rationale for sharing these results.  
Routine clinical data can be shared with PCPs to potentially avoid additional testing and expense. 
• 
How results will be shared.  
Please refer to the patient results form. 
• 
For individual subject results, specify if subjects have the option to opt-in or opt-out of receiving 
these results or allowing these results to be shared with others.  
The subjects have the option to opt out of receiving their study results and can determine if they will 
share them with others. 
• 
Any referral policies (i.e. for confirmation of any individual subject results).  
If a subject is screened out of the study, for example meeting exclusion criteria, the subject will be 
offered to contact the appropriate health care provider. In Cleveland, one subject was determined to 
be ineligible because of hypertension, which required treatment, and the subject was referred to her 
PCP for medical treatment. 
• 
Whether testing of research specimens is being conducted in, a laboratory certified (CLIA-approved) 
to conduct diagnostic testing. If patient-specific research results are reported from the laboratory and 
those results will or could be used for the diagnosis, prevention, or treatment of any disease or 
impairment, or the assessment of the health of human beings, the laboratory must be CLIA certified. 
All laboratory studies provided to patients are performed at CLIA approved laboratories at TMC. 
o If the research tests are experimental or of unknown or unproven clinical significance and the 
results will be provided to the source individual or physician or placed in the source 
individual’s medical record, provide the rationale for this. 
NA 
 
11 Addendums 
11.1 Site Specific Changes: Pennington Biomedical Research Center 
 
Section 2.2 Risk to Subjects 
• 
Adequacy of Protection Against Risks 
o The site PI or designee (Medical Investigator, Dr. Daniel Hsia, MD) will make the final 
decision regarding eligibility.  
 
Section 4.4.1 Local Recruitment Methods 
• 
Source of subjects (for example, patient population, local community, etc.).  
Yes
No
Yes
No

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o Postpartum patients at local Baton Rouge area hospitals that perform deliveries, women 
attending local women’s health events, women responding to web- and flyer-based 
recruitment advertisements. 
• 
Methods that will be used to identify potential subjects.  
o Trialfacts: A web-based recruitment screening process (https://trialfacts.com/).  
▪ 
Trialfacts creates all the advertising and recruitment material used in the 
recruitment process, including study information pages, landing pages, pre-
screening questionnaires, and online advertisements. Pennington Biomedical 
Research Center creates an additional landing page and screening questionnaire 
for those that pass the Trialfacts pre-screening process. 
o Physician assisted recruitment at Baton Rouge General, whereby providers at Baton Rouge 
General discuss the study and handout flyers to potential participants at their discretion.  
o Posted flyers throughout the Greater Baton Rouge area in approved locations. 
o Community events 
• 
Materials that will be used to recruit subjects.  
o Handouts, flyers, physician referrals and online screening material will be used to recruit 
subjects. 
• 
When subjects respond to recruitment material, describe the information that will be provided to 
them about the study and the information that will be collected from subjects (e.g. name, telephone 
number, etc.) or submit a telephone/email script that will be used. 
o Subjects will be contacted via phone by research staff and/or directed to Pennington’s Web 
Screener Initiator (Web screener link: https://my.pbrc.edu/Clinic/Screener/Steps/Step1). 
o If data will be retained for subjects that are determined to be ineligible, specify how privacy 
and confidentiality of these potential subjects will be maintained. Data will be retained 
until the primary manuscript is written noting differences in the study population that have 
determined to be ineligible for whatever reason based on inclusion/exclusion criteria. 
▪ 
Pennington Biomedical has a Notice of Privacy Practices for Protected Health 
Information (provided below). 
• 
If recruitment material is being mailed or otherwise distributed, describe where/how, the 
distribution list will be obtained.  
o An email listserv with IRB approved information will be sent approximately every 
quarter to people who have subscribed to the PBRC email list.  
 
• 
Specify how and why the listed recruitment methods will be effective in attracting the targeted 
subject population.  
o Pennington Biomedical does not provide women’s health and reproductive services and as 
such, necessitates community involvement and hospital partnerships for recruitment. This 
has been successful in enrolling 12 research participants to date. 
 
Section 5.1 Study Design 
• 
Resting Energy Expenditure 
o Resting Metabolic Rate (RMR) will be determined after an overnight fast using a Deltatrac 
II indirect calorimeter (Datex-Ohmeda, General Electrics, Finland) with a canopy system. 
• 
Neonatal Measures 
o A PEAPOD is housed at Pennington Biomedical Research Center. 
o Pennington Biomedical staff will perform requisite tissue collection at local Baton Rouge 
hospitals dependent on where the participant delivers (Legal agreements are provided for 
Baton Rouge General and Women’s Hospital, while the Ochsner legal agreement is 
pending). After hospital discharge, participants will travel to Pennington Biomedical where 
a PEAPOD measure and neonatal anthropometrics will be performed. If travel is difficult, 
neonatal anthropometrics may be obtained at respective hospitals. 

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o Additionally, a medical release form will be obtained from the participant for the purpose 
of obtaining the antenatal chart. 
o Finally, neonatal anthropometrics, caliper measurements and circumference measures may 
be conducted at the houses of PBRC-enrolled study participants if they are unable to travel 
to the PBRC site after delivery. 
• 
Lifestyle Intervention Group 
o Supervised Exercise Intervention 
▪ 
Exercise sessions will be conducted at Pennington Biomedical Fitness Center by 
the Intervention Resources Department at Pennington Biomedical. (See additional 
descriptions below.) 
 
Section 5.3 Evaluations 
• 
All laboratory tests will be performed by the Pennington Biomedical Clinic, Kirwan Lab Team 
and/or analyzed by the Clinical Chemistry Core at Pennington Biomedical. (See additional 
descriptions below.) 
• 
Sample Handling & Storage 
o Sample processing and storage will occur locally at PBRC, following the description in the 
parent protocol. 
• 
Cord blood collection and placenta collection at delivery 
o This process is described in detail in our Standard Operating Procedures (SOP 2304 
Placenta Collection and Processing). In brief, LIPP research staff (Caitlin Hebert) will 
collect tissue specimens from the research participant's delivering hospital. Samples will 
be collected according to protocol and placed on ice or liquid nitrogen. The samples will 
then be immediately transported by Caitlin Hebert to PBRC for further processing and 
storage by LIPP staff (Kirwan Lab personnel) until analysis. The clinical chemistry core 
will perform glucose and lipid profiles on cord blood samples. When the research 
participant is admitted to their delivering hospital’s delivery unit, they will hand the PBRC 
Placental Biospecimens Delivery Unit Information sheet to the attending physician. 
 
Section 6.1 Informed Consent Process 
• 
The PBRC site provides additional informed consent to the infants born to enrolled mothers. This 
informed consent is performed with the LIPP participant at the PBRC site during the final study 
visit (infant measurements) or may be conducted offsite if participants are unable to travel to PBRC 
after delivery. 
 
Interventional Resources 
Expertise including Facilities, Equipment, & Resource Descriptions 
 
Fitness Center 
Pennington Biomedical includes a 2300-square-foot Exercise Training Facility. The facility offers state-of the-art 
equipment, professional intervention technicians, and optimal training data-capturing capabilities. Staff have the 
ability to collect and enter data in real-time via a standing desk with dual monitors to operate the heart rate software, 
databases, and drive files as needed. The cardiovascular fitness training room contains 12 treadmills, 6 stationary 
bikes, and 2 elliptical while the strength training room has an extensive set of machines and free weights. There are 
3 private rooms for intervention related counseling in a one-on-one or small group setting. For measurements, 
there’s a private exam room complete with scale, stadiometer, and computer. In addition, there’s a meeting room 
space capable of outfitting group exercise classes, group presentations, study orientations or introductory sessions, 
or childcare facility for study participants. The Fitness Center is supported by a trained staff composed of full-time 
exercise interventionists and students working on exercise-related degrees.  
The facility is participant friendly and includes televisions, reading materials and enthusiastic staff who are well 
trained in customer service. Further, there are locker rooms equipped with lockers and showers available exclusively 

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for the use of study participants. The facility has a defibrillator, electronic scales, and multiple heart rate monitors 
systems (Polar and Zephr Bioharness). There is an outdoor walking track as well. The scenic walking track is 12 
feet wide, paved, lighted and well-maintained. While the track is over half a mile in length there are 3 intermediate 
circle turn-outs that can be used to create shorter walking courses. All exercise intervention areas at Pennington are 
located in buildings far from the clinical assessment area with virtually no opportunity for assessment staff to 
accidentally observe exercising participants. 
We have developed a real-time web-based system (EDIN2.0) that allows exercise interventionists to efficiently 
maintain accurate records of each exercise session. The progression of each participant is tracked both within 
individual sessions and during the entire study. Exercise can occur on a treadmill, elliptical, or cycle ergometer with 
the speed/grade/resistance modulated in order to keep participants at their target heart rate (±3 beats) derived from 
the maximal exercise testing. EDIN also allows for data capture of acute energy expenditure submaximal tests and 
manual entries such as outdoor exercise or resistance training. 
Resource Descriptions 
Exercise Interventionists & Research Specialists 
Interventional Resources has 7-10 full time interventionists or specialists, and approximately 8-10 students (varied 
by paid, interns, and volunteer status). The Interventionists and Specialists are primarily responsible for participant 
contact activities which include but are not limited to conducting orientations, run-ins, collecting assessment data, 
physical activity or other devices, randomization assignment, and setting up and conducting the physical activity 
and other interventions. They are responsible for ongoing participant contact, maintaining participant records, 
tracking compliance and completing data entry requirements. 
 
11.2 Opt-In Ancillary Studies 
 
11.2.1 Breast Milk Collection 
 
Aim: To determine the impact of the lifestyle intervention on breastfeeding outcomes and breast milk composition 
of the index pregnancy.  
 
Hypothesis: Our overall hypothesis is that women randomized to the lifestyle intervention group will have higher 
rates of breastfeeding and less pro-inflammatory breast milk composition with a lower omega-6/omega-3 fatty 
acid ratio.  
 
Methods: 
a. 
Breastfeeding outcomes: Our exposure will be randomization group and our outcomes will be 
amount of breastfeeding versus formula feeding, duration of any breastfeeding and duration of 
exclusive breastfeeding. Study staff will administer validated breastfeeding outcome questionnaires 
every other week via text message or email to quantify duration of exclusive and any breastfeeding. 
Statistical analysis: We will use independent samples t-test to analyze the association between 
participation in the lifestyle intervention program on breastfeeding rates during each timepoint of 
questionnaire administration. Next, we will use multivariate logistic regression to further examine the 
adjusted association of lifestyle intervention with rates of breastfeeding, adjusting for key covariates.  
b. 
Breastmilk composition: Our exposure will be participation in the lifestyle intervention program. Our 
outcomes will be breast milk cytokines, PUFAs, leptin and insulin. Study staff will instruct mothers 
to collect breast milk samples and provide a 20 mL sample for this study. Participants will provide 
breast milk samples before initiating the intervention and then at routine study visits scheduled at 3- 
and 6-months following intervention initiation. If mothers indicate that they plan to stop breastfeeding 
based on questionnaires, we will attempt to collect a breast milk sample prior to cessation of 
breastfeeding. PUFAs will be measured using established methods of ultra-high performance liquid 
chromatography-heated electrospray ionization tandem mass spectrometry UHPLC-HESI/MS-MS. 
Insulin will be measured using ELISA or radioimmunoassay. For statistical analysis, we will use 
independent samples t-test to analyze the association between participation in the lifestyle 

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intervention program and the mean concentrations of these breast milk markers. We will then use 
multivariate logistic regression to further examine this association, adjusting for key covariates.  
c. 
Procedures: At each study visit, if a participant is still breastfeeding and consent has been signed for 
this ancillary sub-study, study staff will collect one 10-20mL sample of breast milk. Instructions will 
be provided at the previous study visit so that if desired, a participant can pump their sample at home 
in the morning before arrival. If the sample is provided at the study visit, participants will be asked to 
pump a full breast using their own pump or a disposable manual breast pump that we provide. If 
pumped at the visit, study staff will thoroughly mix/shake the full sample and pour 10-20ml into the 
provided sterile container; if at home, the participant will be given instructions on how to prepare the 
sample. The remainder of the sample will be returned to the subject. This sample will be processed in 
the laboratory and archived at -80oC at Brigham and Women’s Hospital. The samples will be carried 
by the BWH LIPP study staff to BWH where they will be stored in freezers in a secured room in a 
secured building by subject ID number and date of collection to be used for future analysis.  
 
 
The impact of the proposed supplemental work lies in identifying modifiable factors that may impact 
breastfeeding outcomes, offspring growth and adiposity. Results from this study could provide further 
insight into the role of lactational programming in intergenerational obesity.  
 
 
 
12 References 
1. Magkos F, Fraterrigo G, Yoshino J, Okunade AL, Patterson BW, Klein S.  Effects of 
moderate and subsequent progressive weight loss on metabolic function and adipose tissue 
biology in humans with obesity.   Cell Metabolism 2016 Feb 22.pii: s1550-4131(16)30053-5. 
doi: 10.1016/j cmet.2016.02.005(e pub). 
2. Obesity in Pregnancy. American College of Obstetricians and Gynecologists. No. 156, 
December 2015. Obstetrics and Gynecology 126(6).e112-126. 
3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States. 2008-2011. 
N Engl J Med 2016;374:843-52. 
4. Catalano PM.   Increasing maternal obesity and weight gain during pregnancy:   the 
obstetric problems of plentitude. Obstet Gynecol 2007;110:743-4. 
5.     Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the 
distribution of body mass index among US adults, 1999-2010.  JAMA 2012;307:491-7. 
6.     Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body 
mass index among US children and adolescents, 199-2010. JAMA 2012;307:483-90. 
7. Ananth CV, Wen SW.  Trends in fetal growth among singleton gestations in the United 
States and Canada, 1985 through 1998.  Semin Perinatol 2002;26:260-7. 
8.     Surkan PJ, Hsieh CC, Johansson AL, Dickman PW, Cnattingius S.  Reasons for 
increasing trends in large for gestational age births. Obstet Gynecol 2004;104:720-6. 
9. Catalano PM.  Management of obesity in pregnancy.  Obstet Gynecol 2007;109:419-33. 
10.   Donahue SMA, Kleinman KP, Gillman MW, Oken E.  Trends in birth weight and 
gestational length among singleton term births in the United States: 1990-2005. Obstet 
Gynecol 2010;115:357-64. 
11. Gibson KS, Waters TP, Gunzler DD, Catalano PM. A retrospective cohort study of 
factors relating to the longitudinal change in birth weight. BMC Pregnancy Childbirth 2015 
Dec 22;15:344. doi10.1186/S12844-015-0777-8. 
12.   Rasmussen KM, Abrams B, Bodnar LM, Butt NF, Catalano PM, Siega-Riz AM. 
Recommendations for  weight  gain  during  pregnancy  in  the  context  of  the  obesity  
epidemic.   Obstet  Gynecol 2010;116:1191-95. 
13.   Whitaker  RC.  Predicting  preschooler  obesity  at  birth:  the  role  of  maternal  obesity  
in  early pregnancy. Pediatrics 2004;114:e29-e36. 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
Page 50 of 54 
 
 
14.   Boney CM, Verma A, Tucker R, Wohr BR. Metabolic syndrome in childhood: 
association with birth weight, maternal obesity, and gestational diabetes mellitus.  Pediatrics 
2005;115:e290- e296. 
15.   Catalano  PM,  Farrell  K,  Thomas  A,  et  al.    Perinatal  risk  factors for  childhood  
obesity and metabolic dysregulation. Am J Clin Nutr 2009;90:1303-13. 
16.   Philipps LH, Santhakumaran S, Gale C, et al. The diabetic pregnancy and offspring BMI 
in childhood: a systematic review and meta-analysis. Diabetologia 2011;54:1957-66. 
17.  Walsh JM, McGowan CA, Mahony R, Foley ME, McAuliffe FM. Low glycemic index 
diet in pregnancy to prevent macrosomia (ROLO study): randomized control trial.  BMJ 
2012;345:e5605. 
18.   Vinter  CA,  Jensen  DM,  Ovesen  P,  Beck-Nielsen  H,  Jørgensen  JS.  The  LiP  
(Lifestyle  in Pregnancy) Study.  A randomized controlled trial of lifestyle intervention in 360 
obese pregnancy women.  Diabetes Care 2011;34:2502-07. 
19.   Dodd JM, Turnbull D, McPhee AJ, Deussen AJ, Grivell RM, Yelland LN et al. 
Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. 
BMJ 2014:348:g1285. 
20.    Phelan S, Phipps MG, Abrams B, Darroch F, Grantham K, Schaffner A, et al. Does 
behavioral intervention in pregnancy reduce postpartum weight retention? Tweleve-month 
outcomes of the Fit for Delivery randomized trial. Am J of Clin Nutr 2014;99:302-11. 
21. Renault KM, Norgaard K, Nilas L, Carlsen E, Cortes D, Pryds O, Secher NJ. The 
Treatment of Obese Pregnancy Women (TOP) study: a randomized controlled trial of the 
effect of physical activity intervention assessed by pedometer with or without dietary 
intervention in obese pregnant women. Am J Obstet Gynecol 2014;210:134.e1-9. 
22. Poston L, Bell R, Croker H, Flynn AC, Godfrey KM, Goff L, Hayes L, Khazaezadeh N, 
Nelson SM, Oteng-Ntim E, Pasupathy D, Patel N, Robson SC, Sandall J, Sanders TAB, 
Sattar N, Seed PT, Wardle J, Whitworth MK, Briley AL, on behalf of the UPBEAT Trial 
Consortium. Effect of a behavioural  intervention  in  obese  pregnant  women  (the  
UPBEAT  study):  a  multicenter, randomized controlled trial. Lancet Diabetes Endocrinol 
2015, July 10, DOI: 10.1016/S2213-8587(15)00253-3 [Epub ahead of print]. 
23. Sagedal LR, Overby NC, Bere E, Torstveit MK, Lohne-Seiler H, Smastuen M, Hillesund 
ER, Henriksen T, Vrstad I. Lifestyle intervention to limit gestational weight gain: The 
Norweigian Fit for Delivery Randomised Controlled Trial.  BJOG 2016 doi:10.1111/1471-
0528.13862. 
24.   Dodd JM, Grivell RM, Crowther CA, Robinson JS. Antenatal interventions for 
overweight or obese pregnant women: a systematic review of randomized trials. BJOG 
2010;117:1316-26. 
25.   Tanentsapf I, Heitmann BL, Adegboye ARA. 2011.  Systematic review of clinical trials 
on dietary interventions  to  prevent  excessive  weight  gain  during  pregnancy  among  
normal  weight, overweight and obese women.  BMC Pregnancy and Childbirth 2011;11:81. 
26.   Quinlivan JA, Julania s, Lam L. Antenatal dietary interventions in obese pregnant 
women to restrict  gestational  weight gain  to  Institute  of  Medicine  recommendations.    A  
meta-analysis. Obstet Gynecol 2011;118:1395-1401. 
27. Thangaratinam S, Rogozińska E, Jolly K, et al. Effects of interventions in pregnancy on 
maternal weight and obstetric outcomes: meta-analysis of randomized evidence. BMJ 
2011;344:e2088. 
28.   Thangaratinam S, Jolly K. Obesity in pregnancy: a review of reviews on the 
effectiveness of interventions.  BJOG 2010;117:1309-12. 
29. Kiel DW, Dodson EA, Artal R, eBoehmer TK, Leet TL.  Gestational weight gain and 
pregnancy outcomes in obese women. How much is enough? Obstet Gynecol 2007; 110:752-
8. 
30. Oken E, Kleinman KP, Belfort MB, Hammitt JK, Gillman, MW.  Associations of 
gestational weight 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
Page 51 of 54 
 
 
gain with short- and longer-term maternal and child health outcomes.   Am J Epidemiol 2009; 
170:173-80. 
31. Bodnar LM, Siega-Riz AM, Simhan HN, Himes KP, Abrams B.  Severe obesity, 
gestational weight gain, and adverse birth outcomes.  Am J Clin Nutr 2010;91:1642-8. 
32. Catalano PM, Mele L, Landon MB, Ramin SM, Reddy UM, Casey B, Wapner RJ, Varner 
MW, Rouse DJ, Thorp, Jr. JM, Saade G, Sorokin Y, Peaceman AM, Jorge E. Tolosa JE, 
M.S.C.E. for the Eunice Kennedy Shriver National Institute of Child Health and Human 
Development Maternal- Fetal Medicine Units Network. Inadequate weight gain in overweight 
and obese pregnant women: what is the effect on fetal growth?  Am J Obstet Gynecol 
211:137.e1-7, 2014; PMCID: 4117705. 
33. Wallace JM, Bhattacharya S, Campbell DM, Horgan GW.  Inter-pregnancy weight 
change impacts placental weight and is associated with the risk of adverse pregnancy 
outcomes ion the second pregnancy.  BMC Pregnancy and Childbirth 2014:14:40. 
34. Jain AP, Gavard JA, Rice JJ, Catanzaro RB, Artal R, Hopkins SA.  The impact of 
interpregnancy weight change on birth weight in obese women. Am J Obstet Gynecol 
2013;208:205.e1-7. 
35. Ehrlich SF, Hedderson MM, Feng J, Davenport ER, Gunderson EP, Ferrara A.  Change 
in body mass index between pregnancies and the risk of gestational diabetes in a second 
pregnancy. Obstet Gynecol 2011;117:1323-30. 
36. Mostello D, Chang JJ, Allen J, Luehr L, Shyken J, Leet T.  Recurrent Preeclampsia.  The 
effect of weight change between pregnancies. Obstet Gynecol 2010;116:667-72. 
37. Getahun D, Ananth CV, Peltier MR, Salihu HM, Scorza WE.  Changes in pregnancy 
body mass index between the first and second pregnancies and risk of large-for-gestational-
age birth.  Am J Obstet Gynecol 2007;196:530.e1-8. 
38. Bogaerts A, Van den Berg BRH, Ameye L, Witters I, Martens E, Timmerman D, 
Devlieger R. Interpregnancy weight change and risk for adverse perinatal outcome. Obstet 
Gynecol 2013;122:99-1009. 
39. Glazer NL, Hendrickson AF, Schellenbaum GD, Mueller BA.   Weight change and the 
risk of gestational diabetes in obese women.  Epidemiol 2004;15:733-7. 
40. Lovelady CA, Garner KE, Moreno KL, Williams JP. 
The effect of weight loss in 
overweight, lactating women on the growth of their infants.  N Engl J Med 2000;342:449-53. 
41. Colleran  HL,  Lovelady  CA.  Use  of  MyPyramid  Menu  Planner  for  moms  in  a  
weight-loss intervention during lactation. J Acad Nutr Diet 2012;112:553-8. 
42. Stendell-Hollis  NR,  Thompson  PA, West  JL, Wertheim  BC,  Thomson  CA.  A  
comparison  of Mediterranean-style and MyPyramid diets on weight loss and inflammatory 
biomarkers in postpartum breastfeeding women. J Women’s Health 2013;22(1),48-57. 
43. O’Toole ML, Sawicki MA, Artal R. Structured diet and physical activity prevent 
postpartum weight retention.  Journal of Women’s Health 2003;12(10):991-8. 
44.   Nascimento SL, Pudwell J, Surita FG, Adamo KB, Smith GN. The effect of physical 
exercise strategies on weight loss in postpartum women: A systematic review and meta-
analysis. Int J Obesity 2014;38,626-35. 
45.   Rono K, Stach-Lempinen B, Klemetti MM, Kaaja RJ, Poyhonen M, Johan JG, et al. 
Prevention of gestational diabetes through lifestyle intervention: study design and methods of 
a Finnish randomized controlled trial multicenter trial (RADIEL). BMC Pregnancy and 
Childbirth 2014;14:70. 
46.   Villamor  E,  Cnattingius  S.    Interpregnancy  weight  change  and  risk  of  adverse  
pregnancy outcomes: a population-based study.  Lancet 2006:368:1164-70. 
47. Lassance L, Haghiac M, Leahy P, Basu S, Minium J, Zhou J, Reider M, Catalano PM, 
Hauguel-de Mouzon S.  Identification of early transcriptome signatures in placenta exposed 
to insulin and obesity.  Am J Obstet Gynecol 2015;212(5):647.e1-11. 
48.   Hussein YN, Marchetti CM, Krishnan RK, Vrobel TR, Gonzalez F, Kirwan JP. Effects 
of exercise and caloric restriction on insulin resistance and cardiometabolic risk factors in 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
Page 52 of 54 
 
 
older obese adults – A Randomized clinical Trail. J Gerontol A Biol Sci Med Sci 
2009;64A:90-95. 
49.   Institute of Medicine.  Weight gain during pregnancy: reexamining the guidelines.  
Washington, DC: National Academy Press, 2009. 
50. Resi V, Basu S, Haghiac M, et al. Molecular inflammation and adipose tissue matrix 
remodeling precede physiologic adaptations to pregnancy.  Am J Physiol Endocrionol Metab 
2012;303:E832-40. 
51.   Catalano PM, Tyzbir ED, Roman NM, Amini SE, Sims EAH.   Longitudinal changes in 
insulin release  and  insulin  resistance  in  non-obese  pregnant  women.     Am  J  Obstet  
Gynecol 1991;165:1667-1672. 
52.   Catalano PM, Tyzbir ED, Wolfe RR, Roman NM, Amini SB, Sims EAH. Longitudinal 
changes in basal hepatic glucose production and suppression during insulin infusion in 
normal pregnant women.  Am J Obstet Gynecol 1992;167:913-19. 
53.   Catalano PM, Tyzbir ED, Wolfe RR, et al.  Carbohydrate metabolism during pregnancy 
in control subjects  and  women  with  gestational  diabetes.    Am  J  Physiol  1993;264  
(Endocrinol  Metab27):E60-67. 
54.   Catalano PM, Drago NM, Amini SB.  Factors affecting fetal growth and body 
composition.  Am J Obstet Gynecol 1995;172:1459-63.  
55.   Catalano PM, Drago NM, Amini SB.   Maternal carbohydrate metabolism and its 
relationship to fetal growth and body composition.  Am J Obstet Gynecol 1995;172:1464-70. 
56.   Catalano  PM,  Roman-Drago  NM,  Amini  SB,  Sims  EAH.     Longitudinal  changes  
in  body composition and energy balance in lean women with normal and abnormal glucose 
tolerance during pregnancy.  Am J Obstet Gynecol 1998;179:156-65. 
57. Catalano PM, Huston L, Amini SB, Kalhan SC.   Longitudinal changes in glucose 
metabolism during  pregnancy  in  obese  women  with  normal  glucose  tolerance  and  
gestational  diabetes mellitus.  Am J Obstet Gynecol 1999;180: 903-16. 
58.   Catalano PM, Nizielski SE, Shao J, Presley L, Qiao L, Friedman JE. Down-regulated 
IRS-1 and PPAR  in obese women with gestational diabetes:   Relationship to free fatty 
acids during pregnancy.  Am J Physiology (Endocrine Metab) 2002;282:E522-33. 
59.   O’Tierney-Ginn P, Presley L, Myers S, Catalano P.  Placental growth response to 
maternal insulin in early pregnancy.  J Clin Endocrinol Metab 2015;100:159-65. 
60. Lassance L, Haghiac M, Leahy P, Basu S, Minium J, Reider M, Catalano PM, Hauguel-
deMouson S. Identification of early transcriptome signatures in placenta exposed to insulin 
and obesity, Am J Obstet Gynecol 2015;212(5):647.e1-11. 
61. Koontz MB, Gunzler DD, Presley L, Catalano PM. Longitudinal changes in body 
composition: Association with Childhood Obesity. Pediatric Obesity 2014;124(3):e141-4. 
62. Kirwan JP, Varastehpour A, Jing M, et al. Reversal of insulin resistance postpartum is 
linked to enhanced skeletal muscle insulin signaling.  J Clin Endocrinol Metab 2004;89:4678-
84. 
63.   Friedman  JE,  Kirwan  JP,  Jin  M,  Presley L,  Catalano  PM.  Increased skeletal  
muscle tumor necrosis factor-1 and impaired insulin signaling persist in obese women with 
gestational diabetes mellitus 1 year postpartum.  Diabetes 2008;57:606-13. 
64.   Solomon TP, Haus JM, Kelly KR, Rocco M, Kashyap SR, Kirwan JP.  Improved 
pancreatic beta- cell function in type 2 diabetic patients after lifestyle-induced weight loss is 
related to glucose- dependent insulinotropic polypeptide. Diabetes Care 2010;33:1561-6. 
65.   Solomon TP, Haus JM, Kelly KR, Cook MD, Filion J, Rocco M, Kashyap SR, 
Watanabe RM, Barkoukis H, Kirwan JP.  A low-glycemic index diet combined with exercise 
reduces insulin resistance, postprandial hyperinsulinemia, and glucose-dependent 
insulinotropic polypeptide responses in obese, prediabetic humans.  Am J Clin Nutr 
2010;92:359-69. 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
Page 53 of 54 
 
 
66. Calabuig-Navarro V, Puchowicz M, Glazebrook P, Haghiac M, Catalano PM, Hauguel 
de-Mouzon S, O’Tierney-Ginn PF. Effect of omega-3 supplementation on placental lipid 
metabolism in overweight and obese women. Am J Clinical Nutrition 2016 (in press). 
67.   Ptomey LT, Willis EA, Honas JJ, Mayo MS, Washburn RA, Herrmann SD, Sullivan 
DK, Donnelly JE.  Validity of energy intake estimated by digital photography plus recall in 
overweight and obese young adults.  J Acad Nutr Diet 2015; June 26: DOI 
10.1016/j.jand.2015.05.006 [Epub ahead of print]. 
68. The Look AHEAD Study: A description of lifestyle intervention and the evidence 
supporting it. The Look AHEAD Research Group.  Obesity (Silver Spring) Author 
Manuscript; available in PMC 2009 January 2.  Published in final edited form as: Obesity 
Silver Spring) 2006;14:737-52. 
69.   Donnelly, JE, Goetz J, Gibson C, Sullivan DK, Lee R, Smith BK, Lambourne K, Mayo 
MS, Hunt S, Lee JH, Honas JJ, Washburn RA.  Equivalent weight loss for weight 
management programs delivered by phone and clinic.  Obesity 2013 21:1951-9. 
70. Siri WE. Body composition from fluid spaces and density: analysis of methods. 1961. 
Nutrition 1993;9:480-91.  
71.   Catalano PM, Wong WW, Drago NM, Amini SB.  Estimating body composition in late 
gestation:  A new hydration constant for body density and total body water.  Am J Physiol 
1995;268 (Endocrinol Metab 31):E153-58. 
72.   Sady SP,  Carpenter MW, Sady MA,  et al.    Prediction of  VO2max during cycle 
exercise in pregnant women.  J Appl Physiol 1988;65:657-61. 
73.   Watanabe RM, Steil GM, and Bergman RN. Critical evaluation of the combined model 
approach for estimation of prehepatic insulin secretion. Am J Physiol 1998; 74: E172-183. 
74. Carpenter MW, Coustan DR.  Criteria for screening tests for gestational diabetes. Am J 
Obstet Gynecol 1982;144:768-73. 
75.   Jacobson AM, de Groot M, Samson JA.   The evaluation of two measures of quality of 
life in patients with type l and type ll diabetes.  Diabetes Care 1994;17:267-74. 
76. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International 
Quality of Life Assessment (IQOLA) Project.  J Clin Epidemiol 1998;51:903-12. 
77.   Sewell MF, Huston-Presley L, Super DM, Catalano PM.  Increased neonatal fat mass, 
not lean body mass, is associated with maternal obesity. AJOG 2006;195:1100-3. 
78.   Catalano PM, Tyzbir ED, Allen SR, McBean JH, McAuliffe TL.  Evaluation of fetal 
growth by estimation of neonatal body composition. Obstet Gynecol 1992;79/1:46-50. 
79. Catalano PM,  Thomas AJ, Avallone DA, Amini SB.  Anthropometric estimation of 
neonatal body composition.  Am J Obstet Gynecol 1995;173:1176-81. 
80.   Catalano PM, Minium PL, Hauguel-de Mouzon S.  Fetuses of obese mothers develop 
insulin resistance in utero. Diabetes Care 2009;32:1076-80. 
81.  Lindsay CA, Thomas AJ, Catalano PM.   The effect of smoking tobacco on neonatal 
body composition.  Am J Obstet Gynecol 1997;177:1124-8. 
82.   Rohl J, Huston-Presley L, Amini SB, Stepanchak W, Catalano PM.  Factors affecting 
fetal growth and body composition as measured by ultrasound.  Am J Obstet Gynec 
2001;185:1416-20. 
83.   Hashimoto K, Wong WW, Thomas AJ, et al.  Estimation of neonatal body composition: 
Isotope dilution versus total body electrical conductivity.  Biology of the Neonate 
2002;81:170-5. 
84. Uvena-Celebrezze J, Fung C, Thomas AJ, et al.  Relationship of neonatal body 
composition to 
maternal glucose control in women with gestational diabetes mellitus. J Mat-Fet and Neonat 
Med 2002;12:396-401. 
85.   Catalano PM, Thomas A, Huston-Presley L, Amini SB.  Increased fetal adiposity:  A 
very sensitive marker of abnormal in-utero development.  Am J Obstet & Gynecol 
2003;189:1698-704. 

PROTOCOL TITLE: Lifestyle Intervention in Preparation for Pregnancy (LIPP) 
VERSION DATE:  March 31st, 2023 
 
 
 
Page 54 of 54 
 
 
86.   Durnwald C, Huston-Presley L, Amini S, Catalano P.  Evaluation of body composition 
of large for gestational age infants of women with gestational diabetes compared with women 
with normal glucose tolerance.  Am J Obstet Gynecol 2004;191:804-8. 
87.   Singh KA, Huston-Presley LP, Mencin P, Thomas A, Amini SB, Catalano PM.  Birth 
weight and body composition of  neonates born to Caucasian compared with African-
American mothers. Obstet Gynecol 2010;115:998-1002. 
88. Waters TP, Huston-Presley L, Catalano PM.  Neonatal body composition according to 
the revised Institute of Medicine Recommendations for Maternal Weight Gain.  J  Clin  
Endocrinol  Metab2012;97:3648-54. 
89.  Matthews DR, Hosker JP, Rudenski AS et al. Homeostasis model assessment: Insulin 
resistance and β-cellfunction from fasting plasma glucose and insulin concentrations in man. 
Diabetes,1985;28:412-19. 
90.   Lassance L, Haghiac M, Minium J, Catalano P, Hauguel-de Mouzon S. Obesity-induced 
down- regulation of the mitochondrial translocator protein (TSPO) impairs placental steroid 
production. J Clin Endocrinol Metab 2015;100(1):E11-8.  
91.   Visiedo F, Bugatto F, Sánchez V, Cózar-Castellano I, Bartha JL, Perdomo G.  High 
glucose levels reduce fatty acid oxidation and increase triglyceride accumulation in human 
placenta. Am J Physiol Endocrinol Metab 2013;305(2):E205-12. 
92.   Brass E, Hanson E, O'Tierney-Ginn PF. Placental oleic acid uptake is lower in male 
offspring of obese women. Placenta 2013;34(6):503-9. 
93.   Hughes SD, Quaade C, Johnson JH, Ferber S, Newgard CB. Transfection of AtT-20ins 
cells with GLUT-2 but not GLUT-1 confers glucose-stimulated insulin secretion. 
Relationship to glucose metabolism. J Biol Chem 1993;268(20):15205-12. 
94.   Folch J, Lees M, Sloane Stanley GH. A simple method for the isolation and purification of total 
lipides from animal tissues. J Biol Chem 1957;226(1):497-509. 
95. World Health Organization. Appropriate body-mass index for Asian populations and its 
implications for policy and intervention strategies. (2004). Lancet (London, England), 363(9403), 
157–163.  
96. Devaraj, S., Hemarajata, P. & Versalovic, J. The Human Gut Microbiome and Body Metabolism: 
Implications for Obesity and Diabetes. Clin. Chem. 59, 617–628 (2013). 
97. Jumpertz, R. et al. Energy-balance studies reveal associations between gut microbes, caloric load, 
and nutrient absorption in humans123. Am. J. Clin. Nutr. 94, 58–65 (2011). 
98. Lambeth, S. M. et al. Composition, Diversity and Abundance of Gut Microbiome in Prediabetes 
and Type 2 Diabetes. J. Diabetes Obes. 2, 1–7 (2015). 
99. Brown, C. T. et al. Gut Microbiome Metagenomics Analysis Suggests a Functional Model for the 
Development of Autoimmunity for Type 1 Diabetes. PLOS ONE 6, e25792 (2011). 
100. Kuang, Y.-S. et al. Connections between the human gut microbiome and gestational diabetes 
mellitus. GigaScience 6, (2017). 
101. Ferrocino, I. et al. Changes in the gut microbiota composition during pregnancy in patients with 
gestational diabetes mellitus (GDM). Sci. Rep. 8, (2018).