A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms.

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Physical activity and gestational weight gain: a systematic review of observational studies.

BACKGROUND: Now that excessive weight gain during pregnancy is recognized as leading to complications during pregnancy that affect foetal growth, limiting weight gain during pregnancy has become a public health concern. Our aim was to perform a systematic review to assess whether observational studies reported associations between Physical Activity (PA) and Gestational Weight Gain (GWG). We were particularly interested in whether insufficient PA might be associated with high GWG. METHODS: Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we searched the MEDLINE ® databases for articles published up to February 2020 concerning case-control, cohort, and ecological studies assessing the association between PA during pregnancy and the risk of excessive and/or inadequate GWG. RESULTS: 21 observational studies on the PA of pregnant women were screened. 11 of these focused on excessive GWG, and of these a majority tend to show a significant association between various aspects of PA and excessive GWG. However, the results were more mitigated when it came to rate of GWG: three studies found that neither meeting PA recommendations nor high levels of total PA nor time spent in moderate vigorous physical activity (MVPA) or engaged in sedentary behaviour were associated with weekly GWG, while two others suggested that pregnant women not meeting PA guidelines in late pregnancy did have a higher rate of GWG. Of the seven studies investigating total GWG, only one found no association with PA. All studies suggested an inverse association between PA and total GWG - yet not all studies are statistically significant. CONCLUSION: Despite the small number of observational studies selected for our research, our findings support the main international findings, suggesting that active pregnant women gained less weight than inactive women; a lack of PA may therefore contribute to excessive GWG. The limitations of this body of evidence impede the formulation of firm conclusions. Further studies focusing clearly on the general PA assessment classification scheme are called for, to address limitations capable of affecting the strength of association.

Study protocol to explore the social effects of environmental exposure and lifestyle behaviours on pregnancy outcome: an overview of cohort of pregnant women study.

INTRODUCTION: A growing number of international studies have highlighted the adverse consequences of lived experience in the first thousand days of pregnancy and early life on the probability of stillbirth, child mortality, inadequate growth and healthy development during both childhood and adulthood. The lived experience of the fetus inside the womb and at the birth is strongly related to both maternal health during pregnancy and maternal exposure to a set of environmental factors known as 'exposome' characteristics, which include environmental exposure, health behaviours, living conditions, neighbourhood characteristics and socioeconomic profile. The aim of our project is to explore the relationships between exposome characteristics and the health status of pregnant women and their newborns. We are particularly interested in studying the relationships between the social inequality of adverse pregnancy outcomes and (1) short-term exposure to atmospheric pollution (MobiFem project) and (2) pregnancy lifestyle (EnviFem project). METHODS AND ANALYSIS: Ours is a prospective, observational and multisite cohort study of pregnant women, involving one teaching hospital across two sites in the Strasbourg metropolitan area.The research team at University Hospital of Strasbourg (HUS) Health collects data on outcomes and individual characteristics from pregnancy registries, clinical records data and questionnaires administered via email to study participants. Recruitment began in February 2021 and will be complete by December 2021. Participants are recruited from first trimester antenatal ultrasound examinations (conducted on weekdays across both sites); each woman meeting our inclusion criteria enters the cohort at the end of her first trimester. Study participants receive a total of three online questionnaires covering sociodemographic characteristics, travel behaviour patterns and lifestyle. Participants complete these questionnaires at recruitment, during the second and third trimester. The level of personal exposure to air pollution is characterised using a dynamic spatiotemporal trajectory model that describes the main daily movements of pregnant women and the time spent in each place frequented. Univariate, multilevel and Bayesian model will be used to investigate the relationships between exposome characteristics and the health status of pregnant women and their newborns. ETHICS AND DISSEMINATION: Our research was approved by the Commission de Protection des Personnes (CPP) Ile de France VI (Paris) on 9 December 2020 (File reference No. 20.09.15.41703 ID RCB: 2020-A02580-39 and No. 20 080-42137 IDRCB 2020-A02581-38). The Agence Nationale de Sécurité du Médicament was informed of it on 15 December 2020. Findings from the study will be disseminated through publications and international conferences and through presentation at meetings with local stakeholders, researchers and policy-makers. TRIAL REGISTRATION NUMBERS: NCT04705272, NCT04725734.

Adverse Birth Outcomes Related to NO2 and PM Exposure: European Systematic Review and Meta-Analysis.

There is a growing number of international studies on the association between ambient air pollution and adverse pregnancy outcomes, and this systematic review and meta-analysis has been conducted focusing on European countries, to assess the crucial public health issue of this suspected association on this geographical area. A systematic literature search (based on Preferred Reporting Items for Systematic reviews and Meta-Analyses, PRISMA, guidelines) has been performed on all European epidemiological studies published up until 1 April 2020, on the association between maternal exposure during pregnancy to nitrogen dioxide (NO2) or particular matter (PM) and the risk of adverse birth outcomes, including: low birth weight (LBW) and preterm birth (PTB). Fourteen articles were included in the systematic review and nine of them were included in the meta-analysis. Our meta-analysis was conducted for 2 combinations of NO2 exposure related to birth weight and PTB. Our systematic review revealed that risk of LBW increases with the increase of air pollution exposure (including PM10, PM2.5 and NO2) during the whole pregnancy. Our meta-analysis found that birth weight decreases with NO2 increase (pooled beta = -13.63, 95% confidence interval (CI) (-28.03, 0.77)) and the risk of PTB increase for 10 µg/m3 increase in NO2 (pooled odds ratio (OR) = 1.07, 95% CI (0.90, 1.28)). However, the results were not statistically significant. Our finding support the main international results, suggesting that increased air pollution exposure during pregnancy might contribute to adverse birth outcomes, especially LBW. This body of evidence has limitations that impede the formulation of firm conclusions. Further studies, well-focused on European countries, are called to resolve the limitations which could affect the strength of association such as: the exposure assessment, the critical windows of exposure during pregnancy, and the definition of adverse birth outcomes. This analysis of limitations of the current body of research could be used as a baseline for further studies and may serve as basis for reflection for research agenda improvements.

Differential Associations of Walking and Cycling with Body Weight, Body Fat and Fat Distribution - the ACTI-Cités Project.

BACKGROUND: Research on the associations between walking and cycling with obesity-related phenotypes is growing but relies mostly on the use of BMI. The purpose of this study was to analyze associations of walking and cycling behaviors assessed separately with various obesity markers in French adults. METHODS: In 12,776 adult participants (71.3% women) of the on-going NutriNet Santé web-cohort, we assessed by self-report past-month walking and cycling (for commuting, errands and leisure), and obesity measures were taken during a visit at a clinical center (weight, height, waist circumference, and percent body fat by bioimpedance). RESULTS: In analyses not taking into account other types of physical activity (household, leisure), walking more than 2.5 h/week was associated in women with lower weight (-1.8 kg), waist circumference (-1.7 cm) and percent body fat (-1.1%) (all p < 0.001). Cycling more than 1.5 h/week was associated in men and women with lower weight (-4.3 and -1.4 kg, respectively), waist circumference (-4.4 and -2.1 cm, respectively), and percent body fat (-2.5 and -1.9 % respectively) (all p < 0.001). Results were unaltered when analyses were further adjusted on household and leisure physical activity. CONCLUSION: These results show important differences between walking and cycling in their association with obesity markers in men and women. These findings provide some evidence for the need to consider separately walking and cycling when designing public health measures for prevention of obesity in adults.

Individual, Social, and Environmental Correlates of Active Transportation Patterns in French Women.

The objectives were (1) to define physical activity (PA) and sedentary behaviors (SB) patterns in daily life contexts (work, leisure, and transportation) in French working women from NutriNet-Santé web-cohort and (2) to identify pattern(s) of active transportation and their individual, social, and environmental correlates. 23,432 participants completed two questionnaires to evaluate PA and SB in daily life contexts and individual representations of residential neighborhood and transportation modes. Hierarchical cluster analysis was performed which identified 6 distinct movement behavior patterns: (i) active occupation, high sedentary leisure, (ii) sedentary occupation, low leisure, (iii) sedentary transportation, (iv) sedentary occupation and leisure, (v) active transportation, and (vi) active leisure. Multinomial logistic regressions were performed to identify correlates of the "active transportation" cluster. The perceived environmental characteristics positively associated with "active transportation" included "high availability of destinations around home," "presence of bicycle paths," and "low traffic." A "positive image of walking/cycling," the "individual feeling of being physically active," and a "high use of active transport modes by relatives/friends" were positively related to "active transportation," identified as a unique pattern regarding individual and environmental correlates. Identification of PA and SB context-specific patterns will help to understand movement behaviors' complexity and to design interventions to promote active transportation in specific subgroups.

Neighborhood educational disparities in active commuting among women: the effect of distance between the place of residence and the place of work/study (an ACTI-Cités study).

BACKGROUND: Active transportation has been associated with favorable health outcomes. Previous research highlighted the influence of neighborhood educational level on active transportation. However, little is known regarding the effect of commuting distance on social disparities in active commuting. In this regard, women have been poorly studied. The objective of this paper was to evaluate the relationship between neighborhood educational level and active commuting, and to assess whether the commuting distance modifies this relationship in adult women. METHODS: This cross-sectional study is based on a subsample of women from the Nutrinet-Santé web-cohort (N = 1169). Binomial, log-binomial and negative binomial regressions were used to assess the associations between neighborhood education level and (i) the likelihood of reporting any active commuting time, and (ii) the share of commuting time made by active transportation modes. Potential effect measure modification of distance to work on the previous associations was assessed both on the additive and the multiplicative scales. RESULTS: Neighborhood education level was positively associated with the probability of reporting any active commuting time (relative risk = 1.774; p < 0.05) and the share of commuting time spent active (relative risk = 1.423; p < 0.05). The impact of neighborhood education was greater at long distances to work for both outcomes. CONCLUSIONS: Our results suggest that neighborhood educational disparities in active commuting tend to increase with commuting distance among women. Further research is needed to provide geographically driven guidance for health promotion intervention aiming at reducing disparities in active transportation among socioeconomic groups.

Active Mobility and Environment: A Pilot Qualitative Study for the Design of a New Questionnaire.

It is generally accepted that active mobility, mainly walking and cycling, contributes to people's physical and mental health. One of the current challenges is to improve our understanding of this type of behaviour. This study aims to identify factors from the daily-life environment that may be related to active mobility behaviours, in order to design a new questionnaire for a quantitative study of a large adult population. The new questionnaire obtained through this pilot study combines information from interviews with existing questionnaires materials in order to introduce new factors while retaining the factors already assessed. This approach comprises three stages. The first was a content analysis (Reinert method) of interviews with a sample of participants about daily living activities as well as mobility. This stage led to a typology of factors suggested by interviews. The second was a scoping review of the literature in order to identify the active mobility questionnaires currently used in international literature. The last stage was a cross-tabulation of the factors resulting from the written interviews and the questionnaires. A table of the inter-relationships between the interview-based typology and the questionnaires shows discrepancies between factors considered by the existing questionnaires, and factors coming from individual interviews. Independent factors which were ignored in or absent from the questionnaires are the housing situation within the urban structure, overall consideration of the activity space beyond the limits of the residential neighbourhood, the perception of all the transportation modes, and the time scheduling impacting the modes actually used. Our new questionnaire integrates both the usual factors and the new factors that may be related to active mobility behaviours.

Socioeconomic Indicators Are Independently Associated with Nutrient Intake in French Adults: A DEDIPAC Study.

Studies have suggested differential associations of specific indicators of socioeconomic position (SEP) with nutrient intake and a cumulative effect of these indicators on diet. We investigated the independent association of SEP indicators (education, income, occupation) with nutrient intake and their effect modification. This cross-sectional analysis included 91,900 French adults from the NutriNet-Santé cohort. Nutrient intake was estimated using three 24-h records. We investigated associations between the three SEP factors and nutrient intake using sex-stratified analysis of covariance, adjusted for age and energy intake, and associations between income and nutrient intake stratified by education and occupation. Low educated participants had higher protein and cholesterol intakes and lower fibre, vitamin C and beta-carotene intakes. Low income individuals had higher complex carbohydrate intakes, and lower magnesium, potassium, folate and vitamin C intakes. Intakes of vitamin D and alcohol were lower in low occupation individuals. Higher income was associated with higher intakes of fibre, protein, magnesium, potassium, beta-carotene, and folate among low educated persons only, highlighting effect modification. Lower SEP, particularly low education, was associated with lower intakes of nutrients required for a healthy diet. Each SEP indicator was associated with specific differences in nutrient intake suggesting that they underpin different social processes.

Walking and cycling for commuting, leisure and errands: relations with individual characteristics and leisure-time physical activity in a cross-sectional survey (the ACTI-Cités project).

BACKGROUND: Increasing active transport behavior (walking, cycling) throughout the life-course is a key element of physical activity promotion for health. There is, however, a need to better understand the correlates of specific domains of walking and cycling to identify more precisely at-risk populations for public health interventions. In addition, current knowledge of interactions between domains of walking and cycling remains limited. METHODS: We assessed past-month self-reported time spent walking and cycling in three specific domains (commuting, leisure and errands) in 39,295 French adult participants (76.5% women) of the on-going NutriNet Santé web-cohort. Multivariate logistic regression models were used to investigate the associations with socio-demographic and physical activity correlates. RESULTS: Having a transit pass was strongly positively associated with walking for commuting and for errands but was unrelated to walking for leisure or to all domains of cycling. Having a parking space at work was strongly negatively associated with walking for commuting and cycling for commuting. BMI was negatively associated with both walking for leisure and errands, and with the three domains of cycling. Leisure-time physical activity was negatively associated with walking for commuting but was positively associated with the two other domains of walking and with cycling (three domains). Walking for commuting was positively associated with the other domains of walking; cycling for commuting was also positively associated with the other domains of cycling. Walking for commuting was not associated with cycling for commuting. CONCLUSIONS: In adults walking and cycling socio-demographic and physical activity correlates differ by domain (commuting, leisure and errands). Better knowledge of relationships between domains should help to develop interventions focusing not only the right population, but also the right behavior.

Spatial heterogeneity of the relationships between environmental characteristics and active commuting: towards a locally varying social ecological model.

BACKGROUND: According to the social ecological model of health-related behaviors, it is now well accepted that environmental factors influence habitual physical activity. Most previous studies on physical activity determinants have assumed spatial homogeneity across the study area, i.e. that the association between the environment and physical activity is the same whatever the location. The main novelty of our study was to explore geographical variation in the relationships between active commuting (walking and cycling to/from work) and residential environmental characteristics. METHODS: 4,164 adults from the ongoing Nutrinet-Santé web-cohort, residing in and around Paris, France, were studied using a geographically weighted Poisson regression (GWPR) model. Objective environmental variables, including both the built and the socio-economic characteristics around the place of residence of individuals, were assessed by GIS-based measures. Perceived environmental factors (index including safety, aesthetics, and pollution) were reported by questionnaires. RESULTS: Our results show that the influence of the overall neighborhood environment appeared to be more pronounced in the suburban southern part of the study area (Val-de-Marne) compared to Paris inner city, whereas more complex patterns were found elsewhere. Active commuting was positively associated with the built environment only in the southern and northeastern parts of the study area, whereas positive associations with the socio-economic environment were found only in some specific locations in the southern and northern parts of the study area. Similar local variations were observed for the perceived environmental variables. CONCLUSIONS: These results suggest that: (i) when applied to active commuting, the social ecological conceptual framework should be locally nuanced, and (ii) local rather than global targeting of public health policies might be more efficient in promoting active commuting.

Descriptive study of sedentary behaviours in 35,444 French working adults: cross-sectional findings from the ACTI-Cités study.

BACKGROUND: Given the unfavourable health outcomes associated with sedentary behaviours, there is a need to better understand the context in which these behaviours take place to better address this public health concern. We explored self-reported sedentary behaviours by type of day (work/non-work), occupation, and perceptions towards physical activity, in a large sample of adults. METHODS: We assessed sedentary behaviours cross-sectionally in 35,444 working adults (mean ± SD age: 44.5 ± 13.0 y) from the French NutriNet-Santé web-based cohort. Participants self-reported sedentary behaviours, assessed as domain-specific sitting time (work, transport, leisure) and time spent in sedentary entertainment (TV/DVD, computer and other screen-based activities, non-screen-based activities) on workdays and non-workdays, along with occupation type (ranging from mainly sitting to heavy manual work) and perceptions towards physical activity. Associations of each type of sedentary behaviour with occupation type and perceptions towards physical activity were analysed by day type in multiple linear regression analyses. RESULTS: On workdays, adults spent a mean (SD) of 4.17 (3.07) h/day in work sitting, 1.10 (1.69) h/day in transport sitting, 2.19 (1.62) h/day in leisure-time sitting, 1.53 (1.24) h/day viewing TV/DVDs, 2.19 (2.62) h/day on other screen time, and 0.97 (1.49) on non-screen time. On non-workdays, this was 0.85 (1.53) h/day in transport sitting, 3.19 (2.05) h/day in leisure-time sitting, 2.24 (1.76) h/day viewing TV/DVDs, 1.85 (1.74) h/day on other screen time, and 1.30 (1.35) on non-screen time. Time spent in sedentary behaviours differed by occupation type, with more sedentary behaviour outside of work (both sitting and entertainment time), in those with sedentary occupations, especially on workdays. Negative perceptions towards physical activity were associated with more sedentary behaviour outside of work (both sitting and entertainment time), irrespective of day type. CONCLUSIONS: A substantial amount of waking hours was spent in different types of sedentary behaviours on workdays and non-workdays. Being sedentary at work was associated with more sedentary behaviour outside of work. Negative perceptions towards physical activity may influence the amount of time spent in sedentary behaviours. These data should help to better identify target groups in public health interventions to reduce sedentary behaviours in working adults.