Provider advice, pregnant persons’ expectations, and actual gestational weight gain among United States military health care beneficiaries: a secondary analysis of a randomized controlled trial

Abstract

Introduction

: Healthy gestational weight gain (GWG) is associated with improved pregnancy and delivery outcomes. Previous literature shows provider advice and expectations regarding GWG significantly associated with GWG outcomes. In this study, we explore the influence of these factors on GWG in a military population in this secondary analysis of data from a randomized controlled trial.

Materials and methods

Participants (N = 377) came from a completed randomized controlled trial focused on behavioral interventions for healthy GWG and/or postpartum weight loss among TRICARE beneficiaries. At baseline, participants filled out a 5-item questionnaire assessing provider advice and self-expectations for GWG. For the actual GWG primary outcome variable, we calculated the difference between the weight obtained in the first trimester and the weight obtained at 36 weeks of gestation. We used regression models to assess the predictive ability of expectations about GWG on actual GWG.

Results

Participants with higher baseline BMIs were more likely to expect excessive GWG as defined by the National Academy of Medicine (NAM; Overweight: 46.3%, Obesity: 65.4%). Participants’ expectations showed a significant association with actual GWG (OR 2.1, 95% CI 1.29–3.41, p = 0.003). Most participants (64.7%) reported no provider advice about how much weight to gain during their pregnancy. Of those who did receive advice, 55.4% reported that it was within the NAM guidelines.

Conclusions

The study documented infrequent provider advice about GWG in a large sample of TRICARE beneficiaries (i.e., both active duty and non-active duty individuals) and supported an association between self-expectations and later actual GWG. Future studies might test strategies to increase/improve provider advice regarding GWG and to aid pregnant individuals in shaping and achieving their GWG expectations.

Clinical Trial Registration

The trial was prospectively registered on clinicaltrials.gov (NCT 03057808) on February 20, 2017.

Background

Gestational weight gain (GWG) is an important modifiable risk factor for maternal and child health. Excessive GWG is common [1] and is associated with increased risk for gestational diabetes [2, 3] and childhood obesity [4, 5]. Excessive GWG can also lead to postpartum weight retention [6, 7] and long-term weight retention [8, 9]. Because of these serious risks, updated national GWG guidelines for pregnant people in the U.S. were published in 2009 [10].

However, the GWG guidelines appear not universally communicated by health care providers. A recent systematic review found only 69% of pregnant patients reported any provider advice about GWG; of those who reported receiving provider advice, only 50% reported being given advice consistent with the GWG guidelines [11]. Accurate provider recommendations on GWG are essential because previous research has demonstrated that pregnant patients tend to adhere to weight gain advice from their health care providers; specifically, when accurate recommendations were provided, more pregnant patients gained within the GWG guidelines [12]. Actual GWG also appears to be influenced by expectations, that may be developed through both provider advice as well as other factors (e.g., experiences in a previous pregnancy, experiences of family and friends). Specifically, previous research has found that pregnant individuals who expected to gain more GWG than the guidelines were more likely to actually gain excessively [13].

Because the Department of Defense has its own resource (i.e., the Purple Book [14]) that communicates these national GWG guidelines, provider advice and expectations for GWG could be somewhat unique within the U.S. military health care system (TRICARE). However, in a previous study, a similar proportion of TRICARE beneficiaries gained outside GWG guidelines compared to pregnant people who received other sources of health care [15]. In addition, for active duty personnel, there may be greater emphasis on pregnancy-related weight gain because of the requirement that they pass a fitness test at 6–12 months postpartum (depending on the branch, at the time of this study) [16–19]. If they do not pass the fitness test, they are not eligible for promotion and could be discharged, leading to the loss of their career and benefits including health insurance [20]. Thus, examining provider advice and expectations within the military environment may provide a unique perspective.

In the current study, we explored provider advice and expectations for GWG in a diverse military sample. We hypothesized that provider advice for GWG is common within this sample, given the potential for greater emphasis on weight among active duty personnel. Consistent with previous literature [12], we also hypothesized that provider advice in excess of the guidelines would predict actual GWG in excess of the guidelines. Finally, we hypothesized that expectations for GWG in excess of the guidelines would predict actual GWG in excess of the guidelines, consistent with prior research [13].

Method

Data for this secondary analysis came from the Moms Fit 2 Fight randomized controlled trial targeting GWG and postpartum weight loss among TRICARE beneficiaries (i.e., active-duty military personnel, spouses, or other dependents) who were 18 years and older. The study biostatistician randomized participants using a computerized block design based on baseline BMI category and parity status to one of the three intervention conditions (1:1:1 allocation) with allocation concealment to assure balanced assignment to conditions. The three experimental conditions were (1) a GWG intervention only, (2) a postpartum weight loss intervention only, or (3) a combined GWG and postpartum weight loss intervention. Briefly, primary GWG outcomes from this study were that participants who received the GWG intervention gained significantly less weight and were less likely to have excessive GWG compared to those who did not receive the GWG intervention (i.e., participants in the postpartum weight loss-only condition) [21]. The protocol was approved by the Institutional Review Board (IRB) of the 59th Medical Wing (IRB approval number: FWH20200184N) and acknowledged by the University of Tennessee Health Science Center IRB.

Participants

Participants were eligible if they were less than 12 weeks of gestation at the screening visit and less than 13 weeks and 5 days of gestation at randomization. Recruitment did not include individuals with underweight since the prevalence of underweight is approximately 1% in this population [22], precluding stratified randomization and analyses by this BMI category. Exclusion criteria included medical conditions that may make dietary and physical activity changes unsafe, high-risk pregnancies, regular smoking in the 6 months prior to conception, use of medication affecting their weight, unstable psychiatric conditions (e.g., depression, eating disorders), recent substantial weight loss (> 4.5 kg in the past 3 months), or bariatric surgery.

Recruitment and screening

Study recruitment occurred from February 2017 to October 2020 via posters, pregnancy orientation visits within obstetric clinics, listserv advertisements, referrals from health care providers, and word-of-mouth. Initially, participants were patients at one of two military treatment facilities in Texas; however, due to the closure of one of those clinics and the study transitioning to remote assessments due to the COVID-19 pandemic, recruitment expanded to two additional military treatment facilities. Potentially eligible participants presented for a screening visit where research staff assessed full eligibility, obtained informed consent, and collected study measures. Research staff then asked participants to track their diet and exercise for one week with MyFitnessPal, submit their military fitness scores (if they were active duty), and obtain their obstetrician’s clearance for participation. Once participants completed these tasks, they were eligible to be randomized at the baseline visit.

GWG intervention core components

The study team adapted the Moms Fit 2 Fight intervention from the Fit Blue intervention, which was a military-focused adaptation of the Look AHEAD intensive lifestyle intervention [23, 24]. The GWG intervention is described in detail elsewhere [21]. Briefly, interventionists used a stepped-care approach to adapt the intervention intensity level and access to resources based on each participant’s weekly GWG rate in comparison to the guidelines. All intervention steps encouraged participants to engage in daily self-weighing and provided a weekly email with a weight trajectory graph. At each participant’s baseline visit, research staff informed them, regardless of intervention group, of the recommended BMI-tailored GWG goal, according to the 2009 National Academy of Medicine (NAM) guidelines [10]. Participants with normal weight were advised to gain 11.5–16 kg. Participants with overweight were advised to gain 7–11.5 kg. Participants with obesity were advised to gain 5–9 kg. Participants began with a personalized first-trimester calorie goal based on the self-monitoring diary they completed between the screening and baseline visits. Once participants entered the second and third trimesters, the intervention recommended an increase in caloric intake in order to achieve the BMI-tailored GWG goal, consistent with GWG guidelines [10]. Participants who received the GWG intervention received Fitbit activity trackers at randomization and were encouraged to achieve the exercise goal of at least 150 min of moderate exercise per week, unless pregnancy complications warranted physical activity restrictions [10, 25].

Interventionists contacted participants via phone either once a month (Step 1), biweekly (Step 2), or weekly (Step 3) for 20–30 min sessions. For Steps 2 and 3, this call included behavioral skill-focused sessions (e.g., managing restaurant eating, stimulus control, social support). In Steps 2 and 3, participants used the MyFitnessPal app/website to self-monitor dietary intake and physical activity daily. In Step 3, interventionists offered a toolbox with supplemental treatment options (e.g., exercise videos, food scales, and healthy cookbooks) and provided participants two nutritionally appropriate meal replacements (i.e., Better Oats™ oatmeal, Healthy Choice™ frozen meals, and/or Slim Fast™) per day.

Participants who did not receive the GWG intervention only participated in data collection visits during the gestational period and then received a postpartum weight loss intervention starting at 6 weeks postpartum and continuing until 12 months postpartum.

Measures

Research staff collected screening, baseline and follow-up data from 2017 to 2021, including in-person in the military obstetric clinics prior to mid-March 2020 and remotely during the COVID-19 pandemic using smart scales and electronic questionnaires. (Although we planned to mask the assessor to the randomized condition, staff turnover prevented us from blinding the assessor in every instance.) This analysis focuses on those who completed the 32/36 week data collection visit (n = 378, 87.9%). The study team added the GWG expectations measure after the first few baseline visits in 2018; thus, the sample in these secondary analyses is slightly smaller (n = 377; those receiving the GWG intervention, n = 256; those not receiving the GWG intervention, n = 121) than the full study sample (n = 430).

Sociodemographic characteristics

Research assistants collected sociodemographic characteristics (i.e., age, race, ethnicity, education, marital status, military rank) at screening. For analyses, the following categories were used: military status (i.e., active duty, dependent), parity (i.e., nulliparous, primiparous, or multiparous), ethnicity (i.e., Hispanic, non-Hispanic), and race (i.e., White, Black, or other).

Anthropometrics

Unblinded research staff measured each participant’s weight at the screening visit in the first trimester (M = 11.8 gestational weeks, SD = 1.1) as well as at gestational weeks 32 and 36 for calculation of actual GWG. At both time points, participants weighed without shoes, in light clothing, on either a calibrated digital scale (Tanita BWB 800 S) or on the participants’ Body Trace e-scale (during the COVID-19 pandemic). Previous research has demonstrated the comparability between clinic and Body Trace e-scale weights [26]. Research staff measured height in centimeters using a stadiometer at baseline; participants self-reported height during the COVID-19 pandemic. Research staff calculated baseline BMI using the standard formula and generated a categorical BMI variable. The pre-specified primary outcome for the trial was actual GWG at 36 weeks of gestation, calculated by comparing screening weight with weight at 36 weeks. Average weekly GWG was calculated for each participant by dividing overall GWG for each participant by the number of weeks between the participant’s screening visit and the final measured pregnancy weight, using the exact dates of measurement for this calculation. Consistent with the pre-specified protocol [27], researchers used the participant’s weight at gestational week 32 to calculate actual GWG if the participant delivered prior to 36 weeks. Excess GWG was defined as being above the upper bound for recommended second and third trimester GWG: normal weight (> 0.5 kg per week), overweight (> 0.33 kg per week), and obesity (> 0.27 kg per week), consistent with previous research [28].

Provider recommendations on GWG

At the baseline visit (i.e., after their first appointment with their obstetrician to get clearance for participating and to confirm gestational age, but before intervention was initiated), participants completed two questions related to provider recommendations on GWG, similar to previous research [13, 29]. Specifically, participants answered: (1) For your current pregnancy, did your obstetric health provider talk to you about your weight gain? and (2) For your current pregnancy, did your obstetric health care provider provide a specific pregnancy weight recommendation? Response options for both questions were: “Yes”, “No”, and “Don’t remember.” If the participant indicated their provider made a specific GWG recommendation, they also answered: “How many pounds did your obstetric health care provider recommend that you gain?” The participant could respond with a specific range of pounds or indicate they did not remember.

Expectations for GWG

Similar to previous research [13], participants completed two questions related to their expectations for GWG at the baseline visit, before intervention was initiated. Specifically, they answered: “How many pounds do you expect you will gain during your pregnancy?” Response categories included: “10–20 pounds,” “15–25 pounds,” “25–35 pounds,” “28–40 pounds,” or “35–50 pounds.” These response categories match the NAM’s suggested GWG range for each BMI category [10], with one additional, larger GWG option (35–50 pounds). Participants were also asked to respond to an open-ended question: “How did you decide how much weight to gain during your pregnancy?”

Statistical analysis

We performed statistical analyses with SAS/STATv14.2 (SAS Institute Inc., Cary, NC). We generated descriptive statistics—means, standard deviations, frequencies and proportions—as well as unadjusted odds ratios and corresponding 95% confidence intervals for the association between expectations of excessive GWG (i.e., above the NAM guidelines) and actual GWG outcomes, using the originally assigned groups in pre-specified analyses. Analyses regarding provider advice were descriptive, due to the lack of distribution of responses (i.e., too few participants reported receiving advice). We also developed an adjusted ordinal logistic regression model of GWG expectations predicting actual GWG that included intervention condition, screening week, BMI category, age, gestational week at baseline, race, ethnicity, military status, and parity as covariates. We examined the qualitative data from the open-ended question with conventional content analysis.

Results

Demographics

These secondary analyses included 377 participants. We report sample characteristics in Table 1.

Table 1.

Sample characteristics

Characteristic	Value
Baseline BMI category
Normal	123 (32.6%)
Overweight	152 (40.3%)
Obesity	102 (27.1%)
Age (years)	30.6 (4.9)
Gestation week at screening	11.8 (1.1)
Race
American Indian/Alaska Native	2 (0.5%)
Asian	13 (3.5%)
Black	53 (14.1%)
Hawaiian/Pacific Islander	4 (1.1%)
Mixed race	21 (5.57%)
White	254 (67.4%)
Other	30 (8.0%)
Hispanic/Latino	62 (16.5%)
Military status
Active duty	169 (44.8%)
Other TRICARE beneficiaries	208 (55.2%)
Parity
Nulliparous	168 (44.6%)
Primiparous	122 (32.4%)
Multiparous	87 (23.1%)

BMI, body mass index. Data are n (%) or mean (SD)

Differences in expected GWG by baseline BMI category

In sum, 16.1% (n = 60) of participants expected to gain less than the guidelines, 44.2% (n = 165) expected to gain within guidelines, and 39.7% (n = 148) expected to gain more than the NAM guidelines for their baseline BMI. However, these expectations for gaining more than the guidelines differed significantly by baseline BMI category (p < 0.0001). Specifically, only a minority of participants with normal weight (10.5%) expected to gain in excess of the guidelines, whereas about half of participants with overweight (46.3%) and almost two-thirds of participants with obesity (65.4%) expected to gain more than the guidelines (Table 2).

Table 2.

Expectations of gestational weight gain by baseline BMI

Baseline BMI Category	Expected GWG
	Below	Within	Above
Normal	43 (35%)	67 (54.5%)	13 (10.5%)
Overweight	17 (11.4%)	63 (42.3%)	69 (46.3%)
Obesity	0 (0.0%)	35 (34.7%)	66 (65.4%)

Note. Below, within, and above the National Academy of Medicine’s gestational weight gain guidelines for each BMI category. BMI, body mass index. GWG, gestational weight gain. Data are n (%)

Qualitative data indicated 49 out of 377 participants anchored their GWG goals based on their pre-pregnancy weight. About half of the participants who acknowledged weight in their reasoning (24 of 49) explicitly acknowledged the role of pre-pregnancy BMI in setting specific GWG expectations, reflecting an awareness of the GWG guidelines (e.g., “I looked up the recommended weight gain for people of my BMI class”). The other half (25 of 49) who referenced weight in their GWG goals did not recognize BMI-specific guidelines. Instead, many expressed a general desire to manage weight. For example, one participant reported, “I am trying to bring down [my] weight [to be] healthy as I don’t want to gain more and [have] it affect [my] baby and myself.” These responses suggest that among participants who intended to manage their GWG, only some were aware of the BMI-tailored guidelines to determine healthy GWG.

Despite the significant trend in our data for participants with overweight and obesity to expect higher GWG, qualitative data revealed a theme of intending to minimize gain after beginning pregnancy at a higher weight. For example, “I realize I am starting this pregnancy in the ‘obese’ category for BMI and know I need to be very cautious how much weight I gain.” Additionally, “[I have] overweight already so I’m trying to only gain the minimum amount and even lose some.” Still other participants expected excessive GWG despite their hopes or intentions. For example, “Ideally, it should be 10–20 [pounds], but realistically [I] will probably gain 15–25.” These responses suggest that participants may have had concerns about their pregravid weight and/or GWG, doubted their ability to manage weight/GWG, and desired interventions that helped them reach their GWG goals.

Overall, participants most frequently cited their experiences with a previous pregnancy as the reason for their current GWG expectations (127 of 377; e.g., “That’s what I gained last pregnancy”). In several cases, participants hoped to restrict their GWG based on previous experience. For example, “I gained 60 [pounds] my first pregnancy, and my goal is to gain less than half of that weight this pregnancy.” Participants commonly reported seeking out other resources about GWG (92 of 377; e.g., “Pregnancy books” or “An app on [my] phone”). They also reported consulting their friends/family (16 of 377; e.g., “Family member stories” and “Listening to some people at work, they said not to gain more than 20 lbs”). Other participants reported specific strategies that they were using to help them meet their GWG goals (14 of 377; e.g., “[I’ve] been…eating healthier and drinking more water, so [I’m] confident [I] will gain even less than recommended”). Finally, some participants reported simply guessing (54 of 377; e.g., “It seems like it would be a healthy amount”).

Because our sample included active duty military personnel, we postulated that a lack of required physical training during pregnancy, as well as the future fitness test, might impact their GWG expectations. However, only one participant named the lack of required exercise as a consideration in their GWG goals (e.g., “No strict PT [physical training] program”); no participants named the changes in their work duties or a future fitness test requirement as reasons for their expectations.

Expectations’ impact on actual GWG

We examined the impact of participants’ GWG expectations on their actual GWG. Participants who expected to gain more than the guidelines were more likely to actually gain above the guidelines compared to those who expected to gain within or below the guidelines (Crude OR 2.1, 95% CI 1.29–3.41, p = 0.003). After adjusting for covariates (e.g., intervention condition, screening week, BMI category, age, gestational week at baseline, race, ethnicity, military status, and parity), the association between expectations of gaining more than the guidelines and actual excessive GWG was attenuated (Adjusted OR 1.72, 95% CI 0.99–2.99, p = 0.055, see Table 3).

Table 3.

Odds of actual excess weight gain based on expectations

	OR	95% CI	P
GWG Expectation
Above the Guidelines	1.72	0.99–2.99	0.0548
Within Guidelines	Reference
Below the Guidelines	1.02	0.54–1.93	0.9561
Intervention Condition
Those Receiving the GWG Intervention	0.55	0.33–0.91	0.0188
Those Not Receiving the GWG Intervention	Reference
Baseline BMI Category
Normal	Reference
Overweight	3.21	1.67–6.20	0.0005
Obesity	2.25	0.81–6.27	0.1219
Baseline Weight	0.99	0.96–1.01	0.2199
Active Duty Status	1.03	0.64–1.67	0.8971
Race Category
Black	0.38	0.19–0.76	0.0067
White	Reference
Other	0.88	0.48–1.60	0.6750
Ethnicity	0.55	0.29–1.03	0.0632
Age	0.98	0.93–1.03	0.3703
Parity Status
Nulliparous	1.38	0.76–2.52	0.2887
Primiparous	1.60	0.86–2.98	0.1403
Multiparous	Reference

Note. OR: odds ratio; CI: confidence interval; BMI: body mass index; GWG: Gestational Weight Gain

Reported provider advice

Most participants in our sample (64.7%) reported their provider(s) did not give them advice during the first trimester prenatal care visit(s) about how much weight to gain during their pregnancy. Figure 1 shows the proportion of our sample who reported no provider advice; reported advice below, within, or above the guidelines; or reported forgetting their provider’s advice, overall and by each of the baseline BMI category groups. Of the participants who did report receiving provider advice about GWG (n = 115), 62.6% (n = 72) reported receiving advice to gain within the GWG guidelines, 24.1% (n = 26) reported receiving advice to gain above the GWG guidelines, and 14.8% (n = 17) reported receiving advice to gain below the GWG guidelines. Participants with normal weight never reported receiving advice to gain above the GWG guidelines (n = 0); they reported the advice they received mostly fell within the GWG guidelines (87.1%, n = 27) or, rarely, below the guidelines (12.9%, n = 4). Participants with overweight reported receiving advice to gain within the guidelines 54.0% of the time (n = 27), below the guidelines 6.0% of the time (n = 3), and above the GWG guidelines 40.0% of the time (n = 20). Similarly, 52.9% of participants with obesity received advice within the GWG guidelines (n = 18), 29.4% received advice to gain below the guidelines (n = 10), and 17.6% received advice to gain above the GWG guidelines (n = 6).

Fig. 1.

Consistency of participant-reported provider advice with National Academy of Medicine (NAM) guidelines for gestational weight gain

The qualitative data revealed that surprisingly few participants (17.6%, n = 67) reported basing their GWG goal on the advice of their provider (e.g., “By what the doctor told me would be the healthiest for my baby and myself,” “Listen to my doctor’s recommendation”). This number includes participants who received reading material from a hospital or clinic rather than the provider directly. Because patients in our sample were seen by TRICARE providers, we expected many participants to cite the Purple Book, a TRICARE-specific resource. However, only two participants mentioned the Purple Book in their reasons for their GWG expectations.

Discussion

The current study found that pregnant persons with overweight and obesity were more likely to expect excessive GWG than pregnant persons with normal weight. In addition, pregnant persons who expected to gain above the GWG guidelines were significantly more likely to have actual excessive GWG. Participants most often reported receiving no advice about GWG from their medical provider. Those who reported receiving provider advice reported that it aligned with the GWG guidelines only about 62% of the time. Only participants with overweight or obesity in our sample reported receiving advice to gain above the guidelines.

Similar to previous studies [29, 30], just over 40% of participants expected to gain in excess of the GWG guidelines, and participants with overweight and obesity were more likely to expect excessive GWG than participants with normal weight. In previous research, individuals with pregravid overweight reported low self-efficacy in physical activity and healthy eating behaviors [31], which may partly explain why many pregnant persons expect excessive GWG. In addition, there are significant barriers to providing nutritional and physical activity guidance provision within the context of typical clinical care (e.g., lack of time, resources, and relevant training) [32, 33].

Furthermore, this study found that expectations for gaining above the GWG guidelines predicted actual excessive GWG, similar to previous research [13, 30, 34]. A possible mechanism by which expectations predict actual GWG is attitudes about weight and weight management. For example, a previous study found negative attitudes about body image or weight gain to be risk factors for actual excessive GWG, while an internal locus of control and self-efficacy for healthy eating were protective factors against actual excessive GWG [34]. However, the strength of the expectations-to-gain relationship demonstrated here is not as large as what other studies have reported [13]. This effect may have been dampened by the effect of Moms Fit 2 Fight intervention that successfully reduced the likelihood of actual excessive GWG [21].

Most participants in this sample reported receiving no advice about GWG from their medical provider, consistent with previous literature [11–13, 29]. In our study, pregnant patients who received provider advice reported that it aligned with the GWG guidelines about two-thirds of the time (62.6%), which is less than in a previous study (85%) [29]. This finding is particularly surprising given the increased importance of weight management within the Department of Defense, which we hypothesized would be associated with increased prevalence of provider advice in this sample. Another noteworthy trend in our sample was that only participants with overweight and obesity reported receiving advice to gain above the GWG guidelines. Other researchers have documented this finding [29] and suggested that providers may offer uniform recommendations to all pregnant patients without tailoring for BMI category, or they may offer higher recommendations to acknowledge or accommodate a perceived likelihood of excessive GWG. In either case, providers may benefit from assistance in generating BMI-tailored GWG recommendations and tracking GWG progress throughout pregnancy. For example, studies have documented both provider enthusiasm about a GWG tool integrated into the patient’s electronic medical record (EMR) [35] and the effectiveness of an EMR tool in improving the accuracy of GWG advice [36]. Tools such as an EMR-integrated GWG tool might increase the frequency, accuracy, and impact of provider advice regarding healthy GWG.

While provider advice regarding GWG is often delivered early in pregnancy, weight gain in the second trimester may be more predictive of eventual total GWG [37]. Thus, in addition to providing GWG advice early in pregnancy, it may be helpful for the GWG guidance to continue throughout pregnancy, which could be facilitated by EMR tracking of the GWG trajectory. In a previous qualitative study [12], participants expressed a desire for providers to discuss weight gain with all patients throughout pregnancy, especially beginning with a consideration of the patient’s comfort discussing weight and weight gain. This desire is reflected in our qualitative data, too, in which participants expressed concern about managing GWG. Although our study did not focus on the timing or frequency of provider advice, our successful GWG intervention featured tailored problem solving delivered when a participant’s GWG deviated from the recommended trajectory throughout pregnancy. It will be important in future research to examine the most effective timing and content of provider advice.

One challenge with one-time provider advice regarding GWG may be the accessibility of advice. In our data, participants most often based their GWG expectations on a previous pregnancy or resources they sought out themselves, perhaps because these sources are more proximal or more specific than their provider’s advice. For example, pregnant persons may expect to “eat for two” [31], which may contribute to excessive GWG. Thus, a provider’s GWG advice might be more meaningful if it includes a warning about colloquial GWG beliefs or a discussion of behavioral goals that might be helpful in meeting GWG goals.

There were several strengths of this study, including a large, diverse sample of active duty personnel and other TRICARE beneficiaries. The diversity in parity status in our sample (i.e., nulliparous, primiparous, and multiparous participants) enabled the inclusion of parity as a covariate in our model. While parity was not a significant covariate in our model, it has been a significant moderator of GWG expectations in previous research [29] and experiences in previous pregnancies were frequently mentioned by participants in the current research as being important in guiding their GWG goals. Similarly, the variety of TRICARE beneficiaries in our sample (i.e., active duty as well as their civilian family members) enabled the inclusion of active duty status as a covariate in our model of GWG expectations. Despite postpartum fitness test requirements, active duty status was not a significant covariate, suggesting that GWG expectations may not differ between pregnant persons who are active duty and those who are other types of TRICARE beneficiaries. It is important, however, to note the limitations of this research; specifically, provider advice was measured by participant report based on their experience of prenatal care in the first trimester only, and participants primarily represented the Air Force and Army branches of the military. We also did not collect data on the types of providers who saw the patients in our study and may have provided (or did not provide) GWG advice in the first trimester. In addition, providers might have known that their pregnant patients were part of a GWG study and might have opted not to offer advice for that reason. Further, GWG was calculated based on the final measured weight at 32 or 36 weeks of gestation; thus, it is possible that we misclassified a few participants who experienced GWG plateaus in the final weeks of pregnancy. Finally, the successful GWG intervention appears to have somewhat dampened the effect of the relationship between expectations and actual GWG; however, most patients do not have access to a GWG intervention and thus, the findings likely are relevant for the majority of patients experiencing usual prenatal care.

Conclusion

The main findings of this study were that expectations of excessive GWG predicted actual GWG, and provider advice regarding GWG goals was relatively uncommon. Future research might explore reasons for the infrequency with which pregnant persons report receiving provider advice (e.g., are the providers not communicating the guidelines or are patients not hearing the guidelines in information-rich first prenatal visits? ), solutions to this trend (e.g., GWG tools for health care providers), and greater understanding of what mediates or moderates the relationship between GWG expectations and actual GWG.

Author contributions

RAK designed this research. ZB analyzed the data. ES, AM, and RAK drafted the manuscript. All authors read and approved the final manuscript.

Funding

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK104872) of the National Institutes of Health, with the title of “Behavioral Weight Management for Pregnant and Postpartum Women in the Military” (Krukowski, Principal Investigator).

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions from the primary Institutional Review Board but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The protocol was approved by the Institutional Review Board (IRB) of the 59th Medical Wing (IRB approval number: FWH20200184N) and acknowledged by the University of Tennessee Health Science Center IRB. All participants provided their written informed consent to participate in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.