1380 Diabetes Care Volume 42, August 2019

Jürgen Harreiter,1 David Simmons,2,3

Nutritional Lifestyle Intervention Gernot Desoye,4 Rosa Corcoy,5,6
CLIN CARE/EDUCATION/NUTRITION/PSYCHOSOCIAL

Juan M. Adelantado,5 Roland Devlieger,7,8,9

in Obese Pregnant Women, Sander Galjaard,7,8,10 Peter Damm,11,12
Elisabeth R. Mathiesen,11,12
Including Lower Carbohydrate Dorte M. Jensen,13,14,15
Lise Lotte T. Andersen,14,15
Intake, Is Associated With Fidelma Dunne,16 Annunziata Lapolla,17
Maria G. Dalfra,17 Alessandra Bertolotto,18
Increased Maternal Free Fatty Ewa Wender-Ozegowska,19
Agnieszka Zawiejska,19 Urszula Mantaj,19
Acids, 3-b-Hydroxybutyrate, and David Hill,20 Judith G.M. Jelsma,21,22
Frank J. Snoek,21,23 Michael Leutner,1
Fasting Glucose Concentrations: Christian Lackinger,24 Christof Worda,25
Dagmar Bancher-Todesca,25
A Secondary Factorial Analysis Hubert Scharnagl,26
Mireille N.M. van Poppel,21,22,27 and
of the European Multicenter, Alexandra Kautzky-Willer1

Randomized Controlled DALI 1

Gender Medicine Unit, Division of Endocrinology
Lifestyle Intervention Trial and Metabolism, Department of Medicine III,
Medical University of Vienna, Vienna, Austria
2
Diabetes Care 2019;42:1380–1389 | https://doi.org/10.2337/dc19-0418 Institute of Metabolic Science, Addenbrookes
Hospital, Cambridge, England
3
Macarthur Clinical School, Western Sydney Uni-
versity, Sydney, New South Wales, Australia
4
OBJECTIVE Department of Obstetrics and Gynecology,
Medical University of Graz, Graz, Austria
In our randomized controlled trial, we investigated the impact of healthy eating 5
Institut de Recerca de l’Hospital de la Santa
(HE) aiming for restricted gestational weight gain (GWG) and physical activity Creu i Sant Pau, Barcelona, Spain
6
(PA) interventions on maternal and neonatal lipid metabolism. Biomaterials and Nanotechnology, CIBER Bio-
engineering, Instituto de Salud Carlos III, Madrid,
RESEARCH DESIGN AND METHODS Spain
7
Department of Development and Regeneration,
Obese pregnant women (n = 436) were included before 20 weeks’ gestation and
KU Leuven, University Leuven, Leuven, Belgium
underwent glucose testing (oral glucose tolerance test) and lipid profiling at 8
Department of Obstetrics and Gynecology, Uni-
baseline and 24–28 and 35–37 gestational weeks after an at least 10-h overnight versity Hospitals Leuven, Leuven, Belgium
9
fast. This secondary analysis had a factorial design with comparison of HE (n = 221) Department of Obstetrics, Gynecology, and
Fertility, GZA Sint-Augustinus Wilrijk, Antwerpen,
versus no HE (n = 215) and PA (n = 218) versus no PA (n = 218). Maternal changes Belgium
in triglycerides (TG), LDL cholesterol, HDL cholesterol, free fatty acids (FFAs), and 10
Department of Obstetrics and Gynaecology,
leptin from baseline to end of pregnancy and neonatal outcomes were analyzed Division of Obstetrics and Prenatal Medicine,
using general linear models with adjustment for relevant parameters. Erasmus University Medical Centre Rotterdam,
Rotterdam, the Netherlands
11
RESULTS Center for Pregnant Women with Diabetes,
Departments of Endocrinology and Obstetrics,
At 24–28 weeks’ gestation, FFAs (mean 6 SD, 0.60 6 0.19 vs. 0.55 6 0.17 mmol/L, Rigshospitalet, Copenhagen, Denmark
P < 0.01) were increased after adjustment for FFA at baseline, maternal age, BMI 12
The Clinical Institute of Medicine, Faculty of
at time of examination, gestational week, insulin resistance, self-reported food Health and Medical Sciences, University of
Copenhagen, Copenhagen, Denmark
intake, self-reported physical activity, and maternal smoking, and GWG was lower 13
Steno Diabetes Center Odense, Odense Univer-
(3.3 6 2.6 vs. 4.3 6 2.8 kg, P < 0.001, adjusted mean differences 21.0 [95% sity Hospital, Odense, Denmark
CI 21.5; 20.5]) in HE versus no HE. Fasting glucose levels (4.7 6 0.4 vs. 4.6 6 14
Department of Gynaecology and Obstetrics,
0.4 mmol/L, P < 0.05) and 3-b-hydroxybutyrate (3BHB) (0.082 6 0.065 vs. 0.068 6 Odense University Hospital, Odense, Denmark
15
Department of Clinical Research, Faculty of
0.067 mmol/L, P < 0.05) were higher in HE. Significant negative associations Health, University of Southern Denmark,
between carbohydrate intake and FFA, 3BHB, and fasting glucose at 24–28 weeks’ Sønderborg, Denmark
16
gestation were observed. No differences between groups were found in oral Galway Diabetes Research Centre and Na-
tional University of Ireland, Galway, Ireland
glucose tolerance test or leptin or TG levels at any time. Furthermore, in PA versus 17
Universita Degli Studi di Padova, Padua, Italy
no PA, no similar changes were found. In cord blood, elevated FFA levels were 18
Azienda Ospedaliero-Universitaria Pisana, Pisa,
found in HE after full adjustment (0.34 6 0.22 vs. 0.29 6 0.16 mmol/L, P = 0.01). Italy
care.diabetesjournals.org
CONCLUSIONS
HE intervention was associated with
reduced GWG, higher FFAs, higher
3BHB, and higher fasting glucose at
24–28 weeks of gestation, suggesting
induction of lipolysis. Increased FFA was
negatively associated with carbohy-
drate intake and was also observed
in cord blood. These findings support
the hypothesis that maternal antenatal
dietary restriction including carbohy-
drates is associated with increased
FFA mobilization.
Maternal obesity is associated with
higher risk of maternal and fetal compli-
cations in pregnancy, such as pregnancy-
induced hypertension, preeclampsia,
large-for-gestational-age babies (LGA),
increased inflammatory processes,
and metabolic derangements (1–3).
Several randomized controlled trials
(RCTs) of lifestyle interventions aimed
to decrease the prevalence of gestatio-
nal diabetes mellitus (GDM) or glycemic
parameters among overweight and
obese women but reported comparable
effects on maternal glucometabolic pa-
rameters at the end of pregnancy be-
tween intervention and control groups,
as well as comparable birth outcomes
(4–6). Progressively, the awareness is
evolving that next to glucose, other
maternal metabolites such as lipids
may also strongly influence maternal
and fetal development and pregnancy
outcome (7,8). Impaired lipid metabo-
lism in pregnancy is associated with a
higher risk of maternal and fetal com-
plications, such as GDM, preeclampsia,
LGA, and preterm delivery, and with
higher fetal fat accretion and neonatal
adiposity, a risk factor for childhood
obesity (7,8).
19
Division of Reproduction, Medical Faculty I,
Poznan University of Medical Sciences, Poznan,
Poland
20
Recherche en Santé Lawson SA, St. Gallen,
Switzerland
21
Amsterdam UMC, Vrije Universiteit Amster-
dam, Amsterdam, the Netherlands
22
Department of Public and Occupational
Health, Amsterdam Public Health Research In-
stitute, Amsterdam, the Netherlands
23
Department of Medical Psychology, Amster-
dam Public Health Research Institute, Amster-
dam, the Netherlands
Due to hormonal changes, maternal
metabolism increases fat storage and
lipogenesis at the beginning to middle
of pregnancy, whereas in the third tri-
mester, higher rates of lipolysis occur,
based on increasing insulin resistance
(IR) and lipolytic hormone actions (9–
11). Lipolysis is increased in obesity due
to higher IR, and increased free fatty
acids (FFAs) interfere with insulin action
and contribute to increasing IR, facilitat-
ing higher glucose levels (7,10,11).
Obese pregnant women have athero-
genic lipid profiles, including increased
triglyceride (TG), VLDL cholesterol, and
FFA and decreased HDL cholesterol
(HDL-C) levels as well as higher glucose
levels and IR and increased inflammatory
parameters, which are all factors that
are associated with adverse pregnancy
outcomes and increased maternal endo-
thelial dysfunction and cardiovascular
disease risk (7,8,12). Maternal TG and
FFAs are associated with fetal macro-
somia or LGA (1,7,8). Excessive fetal lipid
exposure is conjectured to be associated
with augmented fetal fat accumulation
with higher risk of childhood obesity,
fetal hyperinsulinemia, and metabolic
disease (7). In addition, a U-shaped as-
sociation between maternal TG levels in
early pregnancy and congenital anoma-
lies and an increased risk of susceptibility
of the offspring to atherosclerosis based
on epigenetic programming of arterial
cells were reported, which might be
caused by fetal exposure to increased
maternal cholesterol and oxidative by-
products (12,13). Thus, an improvement
of lipid profiles through early lifestyle
intervention in obese pregnant women
might have beneficial effects on mater-
nal and neonatal outcomes.
In this secondary, factorial analysis of
a pan-European lifestyle RCT to prevent
GDM (6), we aimed to investigate the
24
Department for Health Promotion and Preven-
tion, SPORTUNION, Vienna, Austria
25
Division of Obstetrics and Feto-Maternal
Medicine, Department of Obstetrics and Gy-
necology, Medical University of Vienna, Vienna,
Austria
26
Clinical Institute of Medical and Chemical
Laboratory Diagnostics, Medical University of
Graz, Graz, Austria
27
Institute of Sport Science, University of Graz,
Graz, Austria
Corresponding author: Alexandra Kautzky-Willer,
alexandra.kautzky-willer@meduniwien.ac.at
Harreiter and Associates 1381
effect of different lifestyle interventions
(healthy eating [HE] and physical activity
[PA]) on maternal lipid metabolism
from baseline at around week 15 to
the end of gestation as well as on fetal
lipid metabolism, i.e., in cord blood.
RESEARCH DESIGN AND METHODS
Study Design and Participants
DALI (Vitamin D And Lifestyle Intervention
for GDM prevention) was a prospective
multicenter RCT comparing different life-
style approaches that may prevent GDM
progression in obese women recruited
prior to 20 weeks of gestation, as pre-
viously reported (6,14). Thestudyincluded
women (n = 436) from nine European
countries aged $18 years, singleton preg-
nancy before 20 weeks of gestation, pre-
pregnancy BMI $29 kg/m2, and ability to
give informed consent. Exclusion criteria
included preexisting diabetes, need for
complex diets, inability to walk $100 m
safely, or significant chronic medical con-
ditions. Each local research ethics commit-
tee approved the study, and written
informed consent was obtained from all
participating subjects. DALI was registered
in the ISRCTN registry (ISRCTN70595832)
and funded by the European Union 7th
Framework Programme (grant agreement
242187). Recruitment was conducted be-
tween January 2012 and February 2014.
Randomization procedures, blinding,
and sample size calculations were de-
scribed elsewhere (6,14). Obese women
were randomized to four intervention
groups, which were HE (n = 113), PA (n =
110), a combination of both (n = 108), and
usual care (n = 105). A 2 3 2 factorial
design approach was used for factorial
analysis, with generation of groups HE
(n = 221) versus no HE (n = 215) and PA
(n = 218) versus no PA (n = 218) compiled
of the original intervention groups.
Supplementary Fig. 1 gives detailed
Received 27 February 2019 and accepted 12 May
2019
Clinical trial reg. no. ISRCTN70595832, www
.isrctn.org
This article contains Supplementary Data online
at http://care.diabetesjournals.org/lookup/
suppl/doi:10.2337/dc19-0418/-/DC1.
© 2019 by the American Diabetes Association.
Readers may use this article as long as the work
is properly cited, the use is educational and not
for profit, and the work is not altered. More infor-
mation is available at http://www.diabetesjournals
.org/content/license.
1382 DALIdLipids After Lifestyle Intervention
information on group compilation. In-
formation regarding demographics, pre-
pregnancy weight, maternal smoking,
and past/current medical obstetric and
medication history was obtained by
questionnaire.
GDM was diagnosed according to the
International Association of the Diabe-
tes and Pregnancy Study Groups/World
Health Organization 2013 GDM criteria,
and those with GDM at baseline were
excluded. Assessments, oral glucose tol-
erance tests, and blood sampling were
performed before 20 weeks, between
24 and 28 weeks, and between 35 and
37 weeks. Venous cord blood was drawn
immediately after birth.
Lifestyle Interventions
Randomized obese women were as-
signed a lifestyle coach, and each par-
ticipant received individual sessions with
discussion of seven HE and/or five PA
messages (6,14,15) (Supplementary
Table 1). Techniques inspired by moti-
vational interviewing were used to de-
liver the HE and/or PA messages (16). HE
messages aimed to reduce the intake of
sugar/simple carbohydrates in meals and
beverages, decrease fat intake, increase
protein and fiber intake, and regulate
daily calorie intake by watching portion
size. PA messages intended to increase
PA with incorporation into daily routines
by increasing daily activity/steps and
reducing sedentary time, improve
strength (lower/upper limbs), and in-
crease weekend activity (6,14). In total,
five face-to-face sessions and up to
four telephone calls or e-mail contacts
were conducted. To support messages,
a “tool kit” including a participant handboo-
k, educational materials, pedometers (Dig-
iwalker SW-200; Yamax, Tokyo, Japan),
and a flexible elastic dynaband (Thera-
Band, Akron, OH) was provided.
Behavior Measurement
PA and food intake were self-reported
using questionnaires as previously re-
ported (14). In short, PA in pregnancy
was assessed by the Pregnancy Physical
Activity Questionnaire, which allows an
estimate of time spent on PA (i.e., total
PA and moderate-vigorous PA [MVPA])
or sedentary behavior (17). In the DALI
trial, MVPA assessed by the Pregnancy
Physical Activity Questionnaire was sig-
nificantly increased in the PA group
compared with usual care, and sedentary
behavior was reduced in the combined
HE/PA and HE groups (6). To assess di-
etary behavior, a 12-item questionnaire
was used, on which self-reported fre-
quencies (i.e., days per week) and
amounts (i.e., portions per day) of
consumed food were specified, that
was based upon prior work (18). To
obtain a proxy for nutritional compo-
nents, the total number of consumed
food per week of these reported items
was calculated for fiber (i.e., summation
of vegetable, fruit, and whole-grain
bread), protein (i.e., summation of
meat/eggs and fish), carbohydrate
(i.e., summation of cakes/muffins, fruit,
whole-grain bread, fruit juice, nondiet
soft drinks, and potatoes/pasta), and fat
(i.e., summation of high-fat milk prod-
ucts, cakes/muffins, and fast food). Por-
tion size is the summation of all products
that are associated with unfavorable
metabolic effects in women with GDM
(i.e., cakes/muffins, high-fat milk prod-
ucts, nondiet soft drinks, potatoes/pasta,
and fruit juice). Sugar drinks is the sum-
mation of fruit juice and nondiet soft
drinks. All values are given in total num-
ber of items consumed per week.
Laboratory Analyses
Blood samples were obtained after an at
least 10-h overnight fasting period. Fur-
ther samples were taken 60 and 120 min
after 75-g glucose ingestion. Glucose and
insulin analytical procedures have been
reported previously (3,6). From fasting
samples, total cholesterol (TC), TG,
and 3-b-hydroxybutyrate (3BHB) were
measured using colorimetric enzymatic
assays using reagents from DiaSys
Diagnostic Systems (Holzheim, Germany)
and were calibrated using secondary
standards from Roche Diagnostics (Man-
nheim, Germany) (TC and TG) and DiaSys
Diagnostic Systems (3BHB), respectively.
HDL-C was measured with a homogenous
assay from DiaSys Diagnostic Systems,
and LDL cholesterol (LDL-C) was calcu-
lated according to the Friedewald for-
mula (LDL-C = TC 2 HDL-C 2 TG/5).
Nonesterified fatty acids (FFAs) and 3BHB
were analyzed using an enzymatic re-
agent and standards from Wako Chem-
icals (Neuss, Germany). All lipid analyses
were performed on an Olympus AU640
automatic analyzer (Beckman Coulter,
Brea, CA). Leptin was analyzed by
solid-phase sandwich ELISA (E05-086-
96; EIASON, Graz, Austria). Analytical
Diabetes Care Volume 42, August 2019
sensitivity was 1.0 ng/mL; intra- and
interassay coefficients of variability
(low/high concentrations) were 6.0/
6.9% and 11.6/8.7%, respectively.
In venous cord blood, C-peptide was
quantified by chemoluminometric solid-
phase sandwich immune assay (ADVIA
Centaur; Siemens Healthcare Diagnos-
tics, Vienna, Austria). Analytical sensi-
tivity was 0.05 ng/mL and intra- and
interassay coefficients of variability (low/
high concentrations) were 3.7/4.1% and
6.1/6.2%, respectively. All assays were
performed according to the manufac-
turer’s instructions.
Statistical Analysis
Continuous variables were summarized
by means and SDs and categorical var-
iables by counts and percentages. As-
sumption of Gaussian distribution of
parameters was decided by visual assess-
ment of histograms and calculation of
skewness and kurtosis. Skewed data
were log transformed before further
analysis (threshold 62). Comparison
for continuous variables between inter-
vention groups was performed using
Student t test and using x2 test for binary
data. Randomized women were com-
pared with excluded women and women
who dropped out using Student t test.
Correlations were tested using Pearson
test.
Comparisons of TG, LDL-C, HDL-C, FFA,
and leptin from baseline to periods 24–
28 and 35–37 weeks of pregnancy were
made between groups using general
linear regression models. Models were
adjusted for baseline value of the out-
come variable only or adjusted for base-
line value of the outcome variable,
maternal age, BMI at time of exami-
nation, gestational week, IR at time
of examination (HOMA index), self-
reported food intake (portion size),
self-reported PA, and maternal smoking
at time of examination in a fully adjusted
model. Models with weight gain varia-
bles were adjusted for maternal BMI at
baseline. Dietary components and PA
were analyzed after adjustment for base-
line levels using general linear models.
Cord blood lipids were analyzed using
general linear models, adjusting for ges-
tational age at birth and sex in a simple
model and adjusting for gestational age,
sex, maternal age, maternal pregesta-
tional BMI, maternal baseline lipid levels,
and IR (maternal HOMA index and fetal
care.diabetesjournals.org
glucose/C-peptide ratio) in a fully ad-
justed model.
Statistical analysis was performed us-
ing SPSS 25.0 (SPSS Inc., Chicago, IL) and
GraphPad Prism 7 (GraphPad Software,
La Jolla, CA). A two-sided P value ,0.05
was considered statistically significant,
except for lipid parameters and leptin, in
which we used an explorative Simes
procedure to adjust for multiple testing.
The level of discharge was calculated as
P . 0.01.
RESULTS
Baseline Characteristics
Baseline characteristics of randomized,
excluded women and dropout rates are
shown in Table 1. Of 639 women assessed
for inclusion, 168 (26.3%) were excluded
due to GDM diagnosis before 20 weeks of
gestation. Women excluded before ran-
domization had significantly higher levels
of prepregnancy weight, prepregnancy
and baseline BMIs, waist and neck cir-
cumferences, diastolic blood pressure,
TG, glucose and insulin levels during the
oral glucose tolerance test, and IR. They
were more likely to have a history of GDM
in a previous pregnancy or previous
macrosomia. Women who dropped
out after randomization had lower levels
of education, more often a history of
GDM, lower LDL-C and HDL-C levels, and
higher waist circumferences at baseline.
No significant differences between in-
tervention and nonintervention groups
were found except for baseline 3BHB
(P , 0.05), which was increased in HE
versus no HE. The study population was
mainly of European descent (n = 378 of
436, 86.7%) and living with a partner (n =
410 of 436, 94.0%). Diabetes in a first-
degree relative was reported by 23.2%
(n = 101 of 436).
Intervention Effects on Maternal
Lifestyle and Lipid Levels
Descriptive data of metabolic parame-
ters at 24–28 and 35–37 weeks of ges-
tation as well as birth and cord blood
outcomes are shown in Table 2, and data
on self-reported dietary intake and
weight gain are shown in Table 3. At
24–28 weeks of gestation, significantly
lower weight gain and significant higher
FFA, 3BHB, and fasting glucose were
found in HE versus no HE. At 35–37 weeks
of gestation, the HE group had signif-
icantly lower weight gain, lower neck
circumferences, and higher FFA levels.
No differences were found in PA versus
no PA groups. In HE, significant im-
provements in fat intake and portion
sizes at 24–28 weeks and carbohydrate,
sugary drink, and fat intake and portion
sizes at 35–37 weeks of gestation com-
pared with no HE were found after
adjustment for baseline levels. Higher
intake of sugary drinks at 24–28 weeks
and lower fiber intake at 35–37 weeks
of gestation were reported in PA versus
no PA.
In simple regression models, adjusted
for baseline levels, as well as in the fully
adjusted models, significant increased
FFA levels were found at 24–28 (0.086
[95% CI 0.036; 0.137], P = 0.001) and
35–37 (0.087 [0.015; 0.160], P , 0.02)
weeks of gestation in HE versus no HE
(Table 4). In PA versus no PA, a signif-
icant difference was found in the simple
model with lower HDL-C (P , 0.02) at
35–37 weeks of gestation in PA. After
adjustment for multiple testing, significant
differences (P , 0.01) were only found in
FFA levels at 24–28 weeks of gestation
in HE versus no HE.
Correlation Analysis
A significant positive correlation of FFA
and 3BHB (r = 0.46, P , 0.001) at 24–
28 weeks of gestation was found and no
significant correlation between FFA and
fasting glucose (r = 20.05, P = NS). Weak
negative correlations were found be-
tween total carbohydrate intake at
24–28 weeks of gestation and FFA
(r = 20.12, P , 0.03), 3BHB (r = 20.13,
P , 0.02), and fasting glucose (r = 20.11,
P , 0.03) at that time, as well as weak
significant correlations between weight
gain from baseline to 24–28 weeks of
gestation and FFA (r = 20.14, P , 0.01)
and 3BHB (r = 20.14, P , 0.01). No
correlations were found for other nutri-
tional parameters or PA parameters and
FFA, 3BHB, and fasting glucose.
Birth Outcomes and Cord Blood Lipids
At birth, no differences were found in
birth weight, LGA and small for gesta-
tional age, or gestational week of birth in
HE and PA groups compared with no HE/
no PA (Table 2). In HE versus no HE, a
trend for higher mean differences in cord
blood FFA was found (P = 0.057) in a
simple statistical model adjusting for
gestational week and fetal sex, which
became statistically significant (P = 0.009)
in a fully adjusted model (Table 4) and was
Harreiter and Associates 1383
still significant after correction for multiple
testing (P , 0.01). Differences in neonatal
cord blood C-peptide levels (0.69 6
0.47 vs. 0.66 6 0.46 ng/mL, P = NS)
between HE and no HE were not found.
No significant changes in cord blood
lipids or leptin were found in PA versus
no PA.
CONCLUSIONS
Lifestyle Intervention and Maternal
Lipids
At 24–28 weeks of gestation, significant
lower weight gain and increases in FFA,
3BHB, and fasting glucose levels in the HE
group compared with no HE were found
in this secondary factorial analysis. Neg-
ative associations between carbohydrate
intake and FFA, 3BHB, and fasting glu-
cose were found. In cord blood, signif-
icantly higher FFA levels in the HE versus
no HE group were detected. No differ-
ences in other lipids or in the PA versus
no PA groups were identified.
Recently, we reported a significant
weight gain reduction (22 kg) in the
combined HE/PA lifestyle group of the
DALI trial compared with the usual care
group, but we were not able to find
improved metabolic control. We identi-
fied increased fasting glucose levels in
the HE group versus usual care, which we
previously interpreted as a random find-
ing (6). However, now we have an alter-
native interpretation of this finding. The
dietary changes that included decreasing
portion size and a reduction in carbohy-
drate and fat intake, followed by reduced
weight gain in pregnancy, might have
increased FFA and 3BHB levels in the HE
group due to induction of lipolysis in
adipocytes of white adipose tissue. This
could also have affected IR and gluco-
neogenesis and, subsequently, increased
fasting glucose (9,10,19). Nonetheless,
for our analysis, the groups were redis-
tributed, which necessarily impacts on
the interpretation of increased fasting
glucose in the HE group.
We found weak but significant
negative associations of total self-
reported carbohydrate intake with
FFA, 3BHB, and fasting glucose to
support this hypothesis. Moreover, the
negative correlations of weight gain
from baseline to 24–28 gestational
weeks with FFA and 3BHB partly corrob-
orate these findings. A study comparing
complex-carbohydrate/low-fat diet with
 1384

Table 1—Descriptive analysis of women participating in the DALI Lifestyle Study listed per intervention group and in total
Total vs. Total vs.
excluded drop out
HE, n = 221 No HE, n = 215 PA, n = 218 No PA, n = 218 Total, n = 436 Excluded, n = 203 Drop out, n = 44 P P
Age (years) 32.2 (5.4) 31.7 (5.3) 31.8 (5.2) 32.1 (5.5) 32.0 (5.3) 32.3 (5.2) 30.7 (6.1) NS NS
Height (cm) 165.5 (6.6) 165.8 (6.9) 165.8 (6.9) 165.5 (6.7) 165.7 (6.8) 165.9 (6.7) 166.2 (6.9) NS NS
Prepregnancy weight (kg) 92.8 (13.6) 92.5 (12.6) 92.9 (13.5) 92.4 (12.8) 92.7 (13.1) 95.9 (15.8) 94.0 (14.8) ,0.05 NS
Prepregnancy BMI (kg/m2) 33.8 (4.2) 33.6 (3.8) 33.7 (3.9) 33.7 (4.0) 33.7 (4.0) 34.8 (5.0) 34.0 (4.7) ,0.01 NS
DALIdLipids After Lifestyle Intervention

BMI at screening (kg/m2) 34.6 (4.1) 34.4 (3.8) 34.4 (3.9) 34.5 (4.1) 34.5 (4.0) 35.6 (4.9) 35.0 (4.3) ,0.01 NS
Weight gain until first visit (kg)* 2.1 (4.2) 2.0 (4.9) 1.9 (4.6) 2.2 (4.5) 2.1 (4.5) 2.3 (4.4) 2.7 (6.6) NS NS
Gestational week at entry (weeks) 15.3 (2.3) 15.4 (2.3) 15.4 (2.3) 15.2 (2.4) 15.3 (2.3) 15.3 (2.6) 15.2 (2.3) NS NS
Higher education, n (%) 124 of 221 (56.1) 115 of 215 (53.5) 119 of 218 (54.6) 120 of 218 (55.0) 239 of 436 (54.8) 104 of 194 (53.6) 17 of 44 (38.6) NS ,0.05
Multiparity, n (%) 149 of 221 (67.4) 132 of 215 (61.4) 139 of 218 (63.8) 142 of 218 (65.1) 281 of 436 (64.4) 127 of 195 (65.1) 33 of 44 (75.0) NS NS
History of GDM, n (%) 10 of 148 (6.8) 7 of 130 (5.4) 8 of 137 (5.8) 9 of 141 (6.4) 17 of 278 (6.1) 20 of 123 (16.3) 6 of 33 (18.2) ,0.01 ,0.01
Previous macrosomia, n (%) 25 of 145 (17.2) 22 of 129 (17.1) 27 of 134 (20.1) 20 of 140 (14.3) 47 of 274 (17.2) 37 of 124 (29.8) 6 of 31 (19.4) ,0.01 NS
Systolic BP (mmHg) 117.3 (11.2) 116.7 (10.5) 116.8 (11.3) 117.2 (10.4) 117.0 (10.8) 117.0 (9.9) 118.5 (10.6) NS NS
Diastolic BP (mmHg) 74.0 (8.6) 72.5 (8.1) 73.7 (8.2) 72.8 (8.5) 73.2 (8.4) 74.2 (8.0) 74.0 (6.7) ,0.05 NS
Heart rate (bpm) 84.8 (10.7) 84.7 (10.1) 85.4 (10.5) 84.1 (10.2) 79.5 (9.8) 88.0 (11.5) 89.1 (11.3) NS NS
TG (mmol/L) 1.36 (0.49) 1.35 (0.47) 1.32 (0.45) 1.39 (0.52) 1.35 (0.48) 1.50 (0.59) 1.32 (0.46) ,0.01 NS
LDL-C (mmol/L) 3.16 (0.74) 3.12 (0.87) 3.11 (0.85) 3.17 (0.76) 3.14 (0.81) 3.05 (0.94) 2.86 (0.74) NS ,0.05
HDL-C (mmol/L) 1.40 (0.25) 1.41 (0.26) 1.42 (0.26) 1.39 (0.25) 1.40 (0.25) 1.37 (0.28) 1.32 (0.27) NS ,0.05
FFA (mmol/L) 0.64 (0.21) 0.61 (0.20) 0.62 (0.21) 0.63 (0.20) 0.62 (0.20) 0.65 (0.22) 0.62 (0.18) NS NS
3BHB (mmol/L) 0.082 (0.080)# 0.065 (0.068)# 0.075 (0.078) 0.071 (0.072) 0.073 (0.075) 0.078 (0.071) 0.090 (0.096) NS NS
Smoking, n (%) 31 of 221 (14.0) 36 of 214 (16.8) 29 of 217 (13.4) 38 of 218 (17.4) 67 of 435 (15.4) 30 of 193 (15.5) 10 of 44 (22.7) NS NS
Alcohol in pregnancy, n (%) 13 of 221 (5.9) 10 of 214 (4.7) 9 of 217 (4.1) 14 of 218 (6.4) 23 of 435 (5.3) 6 of 192 (3.1) 2 of 44 (4.5) NS NS
Neck circumference (cm) 36.1 (2.1) 36.4 (2.1) 36.2 (2.1) 36.3 (2.1) 36.2 (2.1) 36.8 (2.5) 36.6 (2.0) ,0.01 NS
Waist circumference (cm) 107.4 (10.1) 107.1 (9.5) 107.4 (10.0) 107.2 (9.7) 107.3 (9.8) 109.9 (11.4) 110.8 (12.1) ,0.01 ,0.05
HOMA-IR§ 2.9 (1.3) 3.1 (2.3) 2.8 (1.3) 3.1 (2.3) 3.0 (1.9) 4.2 (2.3) 3.0 (1.7) ,0.001 NS
Fasting glucose (mmol/L) 4.6 (0.4) 4.6 (0.4) 4.6 (0.4) 4.6 (0.4) 4.6 (0.4) 5.1 (0.7) 4.5 (0.4) ,0.001 NS
Fasting insulin (mmol/L)§ 13.9 (6.1) 14.8 (10.6) 13.8 (5.9) 15.0 (10.6) 14.4 (8.6) 18.3 (9.1) 14.7 (7.3) ,0.001 NS
Glucose 60 min (mmol/L) 6.8 (1.4) 6.8 (1.4) 6.7 (1.3) 6.9 (1.4) 6.8 (1.4) 8.1 (2.1) 6.7 (1.3) ,0.001 NS
Insulin 60 min (mmol/L) 104.0 (61.6) 109.6 (70.6) 106.2 (64.2) 107.4 (68.3) 106.8 (66.2) 135.8 (81.0) 113.1 (68.2) ,0.001 NS
Glucose 120 min (mmol/L) 5.9 (1.1) 5.8 (1.1) 5.8 (1.1) 5.9 (1.1) 5.8 (1.4) 6.9 (1.6) 5.6 (1.2) ,0.001 NS
Insulin 120 min (mmol/L)§ 75.1 (51.1) 76.6 (61.9) 75.7 (56.4) 76.1 (57.2) 75.9 (56.7) 113.2 (97.2) 76.1 (64.8) ,0.001 NS
Leptin (ng/dL) 36.4 (20.5) 34.6 (16.7) 35.1 (17.5) 36.0 (19.8) 35.5 (18.7) 37.4 (19.3) 33.3 (23.4) NS NS
Values are mean (SD) except those where n (%) is indicated. BP, blood pressure. *Weight gain prepregnancy to first study visit. §Logarithmically transformed for statistical analysis. #P , 0.05.
Diabetes Care Volume 42, August 2019
care.diabetesjournals.org Harreiter and Associates 1385

Table 2—Primary and secondary outcomes in the two intervention groups and intervention effects at 24–28 and 35–37 weeks
of pregnancy and at birth
HE No HE PA No PA
24–28 weeks n = 204 n = 203 n = 200 n = 207
TG (mmol/L) 1.88 (0.63) 1.85 (0.68) 1.82 (0.61) 1.91 (0.70)
LDL-C (mmol/L) 3.71 (1.02) 3.66 (1.00) 3.65 (0.94) 3.72 (1.07)
HDL-C (mmol/L) 1.45 (0.27) 1.48 (0.27) 1.48 (0.25) 1.45 (0.28)
FFA (mmol/L) 0.60 (0.19)** 0.55 (0.17)** 0.57 (0.20) 0.57 (0.17)
3BHB (mmol/L) 0.082 (0.065)* 0.068 (0.067)* 0.070 (0.061) 0.080 (0.071)
HbA1c (%) 5.1 (0.4) 5.1 (0.4) 5.1 (0.4) 5.1 (0.4)
Leptin (ng/dL) 38.2 (19.1) 35.6 (17.5) 37.1 (19.5) 36.7 (17.2)
Gestational age (weeks) 26.3 (1.4) 26.3 (1.4) 26.3 (1.3) 26.3 (1.4)
Systolic blood pressure (mmHg) 116.6 (11.0) 116.3 (11.0) 116.5 (10.8) 116.5 (11.2)
Diastolic blood pressure (mmHg) 72.0 (8.5) 72.6 (9.1) 72.5 (8.5) 72.1 (9.0)
Heart rate (bpm) 85.1 (10.8) 84.5 (10.1) 85.5 (10.5) 84.1 (10.3)
GDM, n/n (%) 44/200 (22.0) 41/201 (20.4) 41/195 (21.0) 44/206 (21.4)
Fasting glucose (mmol/L)# 4.8 (0.4)* 4.6 (0.4)* 4.6 (0.4) 4.7 (0.4)
Fasting insulin (mU/L) 16.0 (7.3) 16.8 (8.4) 16.4 (7.8) 16.4 (8.0)
Glucose 60 min (mmol/L) 7.9 (1.7) 7.7 (1.6) 7.8 (1.7) 7.8 (1.7)
Insulin 60 min (mU/L) 142.7 (81.6) 137.3 (79.1) 140.5 (85.0) 139.6 (75.9)
Glucose 120 min (mmol/L) 6.3 (1.2) 6.2 (1.3) 6.3 (1.3) 6.3 (1.2)
Insulin 120 min (mU/L) 99.1 (75.0) 101.2 (88.5) 101.6 (88.9) 98.7 (75.0)
Neck circumference (cm) 36.2 (2.2) 36.5 (2.2) 36.2 (2.2) 36.4 (2.3)
HOMA-IR§ 3.4 (1.7) 3.5 (1.8) 3.4 (1.6) 3.5 (1.9)
35–37 weeks n = 181 n = 182 n = 179 n = 184
TG (mmol/L) 2.42 (0.80) 2.27 (0.80) 2.35 (0.77) 2.34 (0.84)
LDL-C (mmol/L) 3.94 (1.03) 3.78 (1.23) 3.80 (1.18) 3.92 (1.09)
HDL-C (mmol/L) 1.40 (0.29) 1.39 (0.30) 1.38 (0.27) 1.42 (0.32)
FFA (mmol/L) 0.64 (0.23)* 0.59 (0.21)* 0.61 (0.24) 0.63 (0.20)
3BHB (mmol/L) 0.107 (0.071) 0.101 (0.092) 0.100 (0.085) 0.108 (0.078)
Leptin (ng/dL) 35.0 (19.0) 36.8 (18.6) 36.5 (19.3) 35.2 (18.3)
HbA1c (%) 5.3 (0.4) 5.3 (0.4) 5.3 (0.4) 5.3 (0.4)
Gestational age (weeks) 35.8 (0.9) 35.9 (1.9) 35.9 (0.9) 35.9 (1.0)
Systolic blood pressure (mmHg) 119.1 (10.3) 118.1 (10.1) 118.8 (10.5) 118.4 (9.9)
Diastolic blood pressure (mmHg) 75.6 (8.7) 75.9 (8.6) 75.9 (8.4) 75.6 (8.9)
Heart rate (bpm) 88.3 (11.4) 86.4 (11.4) 87.0 (11.1) 87.7 (11.7)
GDM, n/n (%) 32/165 (19.4) 35/173 (20.2) 28/167 (16.8) 39/171 (22.8)
Fasting glucose (mmol/L) 4.6 (0.5) 4.5 (0.4) 4.5 (0.5) 4.6 (0.4)
Fasting insulin (mU/L) 19.0 (11.5) 19.7 (12.4) 19.0 (11.1) 19.7 (12.8)
Glucose 60 min (mmol/L) 8.1 (1.5) 8.1 (1.5) 8.1 (1.5) 8.2 (1.4)
Insulin 60 min (mU/L) 188.6 (99.8) 186.9 (122.3) 179.3 (104.8) 196.1 (118.2)
Glucose 120 min (mmol/L) 6.6 (1.2) 6.5 (1.1) 6.4 (1.1) 6.7 (1.2)
Insulin 120 min (mU/L) 142.9 (91.8) 137.6 (116.3) 133.9 (110.8) 146.3 (98.8)
Neck circumference (cm)# 36.4 (2.3)* 36.9 (2.2)* 36.5 (2.3) 36.7 (2.2)
HOMA-IR§ 3.9 (3.0) 4.0 (2.6) 3.8 (2.7) 4.1 (2.8)
Birth and fetal cord blood outcomes n = 200 n = 197 n = 195 n = 202
Gestational age at birth (weeks) 39.5 (2.6) 39.6 (1.6) 39.6 (1.4) 39.5 (2.6)
Birth weight (g) 3,477 (574) 3,494 (524) 3,467 (506) 3,503 (589)
Female sex, n/n (%) 94/200 (47) 105/197 (53) 99/195 (50) 100/202 (50)
SGA, n/n (%) 17/192 (8.9) 11/183 (6.0) 13/180 (7.2) 15/195 (7.7)
LGA, n/n (%) 24/192 (12.5) 28/184 (15.2) 21/181 (11.6) 31/195 (15.9)
Birth weight over 4,000 g, n/n (%) 36/198 (18.2) 35/196 (17.9) 32/194 (16.5) 39/200 (195)
Birth weight below 2,500 g, n/n (%) 8/198 (4.0) 9/196 (4.1) 5/194 (2.6) 11/200 (5.5)
TG (mmol/L) 0.54 (0.45) 0.50 (0.37) 0.54 (0.46) 0.50 (0.37)
LDL-C (mmol/L) 0.95 (0.66) 0.96 (0.75) 0.95 (0.65) 0.95 (0.75)
HDL-C (mmol/L) 0.63 (0.26) 0.65 (0.29) 0.64 (0.28) 0.64 (0.27)
FFA (mmol/L) 0.34 (0.23) 0.29 (0.16) 0.33 (0.21) 0.30 (0.18)
3BHB (mmol/L) 0.23 (0.21) 0.22 (0.20) 0.22 (0.23) 0.23 (0.19)
Leptin 9.8 (9.0) 10.8 (10.9) 9.3 (8.7) 11.1 (10.9)
Glucose (mmol/L) 5.0 (5.9) 5.3 (8. 9) 5.2 (6.1) 5.1 (8.6)
Neonatal sum of skinfolds (mm) 20.6 (5.1) 21.3 (5.2) 20.5 (4.9) 21.4 (5.4)
Data are mean (SD) unless otherwise indicated. SGA, small for gestational age. #Also significant after adjustment for baseline: fasting glucose adjusted
mean difference 0.07 (0.00; 0.14)*, neck circumference adjusted mean difference 20.3 (20.6; 20.2)*. *P , 0.05. **P , 0.01.
1386 DALIdLipids After Lifestyle Intervention Diabetes Care Volume 42, August 2019

Table 3—Nutritional, PA, and weight gain information in the two intervention groups and intervention effects before 20 and
at 24–28 and 35–37 weeks of gestation and mean differences between intervention groups adjusted for baseline levels
Adjusted mean Adjusted mean
HE No HE PA No PA
difference (95% CI) difference (95% CI)
Mean (SD) Mean (SD) HE vs. no HE Mean (SD) Mean (SD) PA vs. no PA
Before 20 weeks of gestation n = 208 n = 203 n = 203 n = 208
Sugar drinks (n/week) 7.1 (9.5) 8.2 (13.1) 9.0 (12.4)* 6.3 (10.1)*
Fiber (n/week) 29.5 (16.9) 31.4 (24.8) 32.8 (24.8)* 28.1 (16.4)*
Protein (n/week) 8.8 (6.4) 10.3 (13.1) 10.2 (13.1) 8.9 (6.4)
Fat (n/week) 6.2 (5.2) 5.8 (5.1) 6.5 (5.4) 5.6 (5.0)
Carbohydrates (n/week) 38.8 (21.1) 41.6 (28.9) 43.9 (28.9)** 36.5 (20.5)**
Portion size (n/week) 21.1 (14.6) 21.4 (16.1) 24.2 (16.7)*** 18.3 (13.2)***
Total PA (MET h/week) 174.2 (91.7) 173.8 (89.1) 179.2 (97.4) 168.2 (82.4)
MVPA (MET h/week) 63.8 (62.8) 66.3 (63.1) 68.1 (65.5) 62.1 (60.1)
Sedentary time (MET h/week) 13.0 (9.6) 13.1 (8.8) 13.2 (8.9) 12.9 (9.5)
24–28 weeks of gestation n = 192 n = 193 n = 189 n = 196
Sugar drinks (n/week) 4.9 (9.7) 6.5 (8.8) 21.4 (23.2; 0.5) 7.2 (11.5) 4.2 (6.2) 2.4 (0.6; 4.2)**
Fiber (n/week) 39.4 (29.7) 35.4 (21.8) 4.8 (20.2; 9.8) 38.1 (30.2) 36.6 (21.6) 20.8 (25.8; 4.3)
Protein (n/week) 9.7 (7.0) 8.8 (5.9) 1.1 (20.2; 2.4) 9.2 (6.0) 9.3 (6.8) 20.3 (21.6; 1.0)
Fat (n/week) 5.2 (5.2) 6.1 (5.5) 21.3 (22.3; 20.2)* 6.0 (5.2) 5.4 (5.6) 0.4 (20.7; 1.4)
Carbohydrates (n/week) 35.8 (20.8) 38.8 (25.2) 22.0 (26.4; 2.3) 38.9 (23.5) 35.9 (22.8) 0.1 (24.3; 4.5)
Portion size (n/week) 16.7 (14.7) 19.2 (13.9) 22.8 (25.4; 20.1)* 20.0 (16.3) 16.0 (11.9) 1.4 (21.3; 4.1)
Total PA (MET h/week) 159.6 (90.2) 161.4 (79.7) 0.3 (213.5; 14.1) 164.1 (84.6) 157.0 (86.2) 1.5 (212.4; 15.4)
MVPA (MET h/week) 57.1 (57.7) 57.5 (53.5) 1.6 (27.5; 10.8) 59.2 (50.0) 55.4 (60.5) 1.7 (27.4; 10.8)
Sedentary time (MET h/week) 11.3 (8.4) 12.8 (8.6) 21.4 (22.8; 0.1) 11.6 (8.1) 12.6 (8.8) 21.1 (22.5; 0.3)
Weight gain (kg) 3.3 (2.7) 4.3 (2.8) 21.0 (21.5; 20.5)*** 3.7 (2.8) 3.9 (2.7) 20.2 (20.7; 0.3)
35–37 weeks of gestation n = 170 n = 162 n = 166 n = 166
Sugar drinks (n/week) 3.4 (4.9) 7.2 (12.0) 23.3 (25.1; 21.4)*** 6 0.3 (11.9) 4.3 (5.6) 1.3 (20.6; 3.2)
Fiber (n/week) 33.4 (19.9) 36.7 (23.0) 21.6 (25.9; 2.6) 33.2 (20.2) 36.9 (22.7) 25.7 (29.9; 21.4)**
Protein (n/week) 9.1 (7.1) 9.1 (6.4) 0.3 (21.2; 1.7) 8.8 (5.1) 9.4 (8.1) 20.7 (22.2; 0.8)
Fat (n/week) 5.2 (4.9) 6.5 (6.5) 21.5 (22.8; 20.3)* 6.0 (5.0) 5.7 (6.5) 0.0 (21.3; 1.2)
Carbohydrates (n/week) 32.8 (20.8) 41.2 (30.6) 26.2 (211.6; 20.9)* 37.7 (29.1) 36.4 (23.8) 21.5 (26.9; 3.9)
Portion size (n/week) 16.0 (13.0) 19.9 (15.7) 23.8 (26.8; 20.9)** 19.4 (16.3) 16.6 (12.6) 0.6 (22.4; 3.6)
Total PA (MET h/week) 137.1 (83.4) 130.6 (71.1) 7.8 (26.4; 22.0) 139.0 (83.0) 129.1 (71.3) 6.2 (28.0; 20.4)
MVPA (MET h/week) 44.2 (56.0) 39.6 (39.0) 5.9 (23.0; 14.9) 44.3 (48.9) 39.5 (47.4) 2.6 (26.4; 11.6)
Sedentary time (MET h/week) 12.0 (8.8) 13.9 (9.1) 21.6 (23.3; 0.0)* 12.3 (8.1) 13.5 (9.8) 21.4 (23.0; 0.3)
Weight gain (kg) 7.0 (4.4) 8.5 (4.7) 21.5 (22.4; 20.5)** 7.4 (4.5) 8.1 (4.7) 20.7 (21.6; 0.2)
Definition of calculation of food scores for each time point (n/week) = frequency per day 3 times per week; sugar drinks: sugar drinks total = fruit juice
total + soft drink total; fiber: total fiber = vegetables total + fruit total + whole-grain bread total; protein: protein total = meat and eggs total + fish total;
fat: fat total = high-fat milk total + cakes and muffins total + fast food total; carbohydrates: carbohydrates total = cakes and muffins total + fruit total +
whole-grain bread total + fruit juice total + soft drink total + potatoes/pasta total; portion size: portion size total = cakes and muffins total + high-fat
milk total + fruit juice total + soft drink total + potatoes/pasta total. *P , 0.05. **P , 0.01. ***P , 0.001.

low-carbohydrate/high-fat diet (carbohy-
drate/fat/protein 60/25/15% vs. 40/45/
15%) also found increased fasting glu-
cose levels in the latter and decreased
FFA, fasting glucose levels, and lipolysis in
adipose tissue and IR in the first group
(20). This study had a small sample size
and reflects only short-term changes
in the last trimester of obese women
affected by GDM but demonstrates
an association of a low-carbohydrate
diet with higher fasting glucose and
FFA levels based on increased lipolysis.
An older pilot study partly corroborates
these findings; after 4 days on a low-
carbohydrate (carbohydrate/fat/protein
35/45/20% and 70 g fiber vs. 70/10/
20% and 31 g fiber) diet, women with
GDM had increased fasting FFA and IR
but no changes in fasting glucose
compared with women on a low-fat/
high–unrefined carbohydrate diet (21). Ke-
tone bodies were not reported (20,21).
Therefore, it seems our dietary inter-
vention may have paradoxically worked
against the goal of preventing GDM by
inducing lipolysis. These findings high-
light the need of further research on the
possible induction of lipolysis by dietary
interventions in pregnancy.
Prior studies have not reported differ-
ences in FFA, other lipids, or leptin in
overweight or obese pregnant women
between lifestyle intervention and con-
trol groups (4,22–24). Differences be-
tween our results and other trials may
be due to the lesser reduction of gesta-
tional weight gain in these studies and
therefore putatively a lesser degree of
lipolysis. The UK Pregnancies Better
Eating and Activity Trial (UPBEAT) re-
ported reduced glycemic index in the
intervention group as well as decreased
total energy, carbohydrate, and satu-
rated and total fat and increased protein
and fiber intake (4), and LIMIT (Limiting
weight gain in overweight and obese
women during pregnancy to improve
health outcomes: a randomised trial)
found increased daily fruit and vegetable
consumption and fiber intake as well as a
reduction of saturated fat intake after
lifestyle advice independent of BMI (5),
whereas the other trials did not focus
their analysis on nutrition and fat intake
(24) or report on diet at all (23). A study
investigating the effect of lower fat in-
take by consuming less saturated and
total fat and cholesterol found decreased
TC, HDL-C, and LDL-C levels at 36 weeks of
care.diabetesjournals.org Harreiter and Associates 1387

Table 4—Mean differences of lipid parameters and leptin; comparisons of HE versus no HE and PA versus no PA
Mean difference (95% CI) Adjusted mean difference Mean difference (95% CI) Adjusted mean difference
HE vs. no HE$ (95% CI) HE vs. no HE$$ PA vs. no PA$ (95% CI) PA vs. no PA$$
24–28 weeks
TG (mmol/L) 20.034 (20.144; 0.075) 20.093 (20.246; 0.059) 20.050 (20.159; 0.060) 20.118 (20.278; 0.041)
LDL-C (mmol/L) 0.020 (20.145; 0.185) 20.068 (20.304; 0.167) 20.031 (20.196; 0.134) 0.100 (20.147; 0.347)
HDL-C (mmol/L) 20.018 (20.061; 0.024) 20.002 (20.063; 0.060) 0.013 (20.030; 0.056) 0.010 (20.054; 0.075)
FFA (mmol/L) 0.038 (0.002; 0.075)* 0.086 (0.036; 0.137)*** 0.000 (20.036; 0.037) 0.002 (20.052; 0.056)
Leptin 2.057 (20.571; 4.684) 1.769 (21.945; 5.484) 20.136 (22.770; 2.498) 0.307 (23.592; 4.206)
35–37 weeks
TG (mmol/L) 0.075 (20.077; 0.227) 0.005 (20.235; 0.245) 0.045 (20.106; 0.196) 0.151 (20.100; 0.402)
LDL-C (mmol/L) 20.043 (20.472; 0.387) 20.126 (20.445; 0.192) 20.043 (20.244; 0.161) 0.257 (20.079; 0.594)
HDL-C (mmol/L) 0.027 (20.030; 0.083) 20.005 (20.095; 0.085) 20.066 (20.122; 20.009)* 20.054 (20.149; 0.040)
FFA (mmol/L) 0.053 (0.005; 0.100)* 0.087 (0.015; 0.160)* 20.025 (20.073; 0.023) 0.015 (20.062; 0.093)
Leptin 21.978 (25.419; 1.463) 24.872 (210.189; 0.446) 0.890 (22.552; 4.331) 20.203 (25.682; 5.276)

Mean difference (95% CI) Adjusted mean difference Mean difference (95% CI) Adjusted mean difference
HE vs. no HE† (95% CI) HE vs. no HE†† PA vs. no PA† (95% CI) PA vs. no PA††

Offspring outcomes
at birth
Gestational age at
birth (weeks) 20.02 (20.33; 0.23) 0.23 (20.16; 0.61) 20.05 (20.36; 0.26) 20.19 (20.58; 0.20)
Birth weight (g) 233 (2124; 58) 243 (2177; 90) 236 (2126; 54) 297 (2231; 37)
TG (mmol/L) 0.042 (20.060; 0.143) 20.007 (20.123; 0.108) 0.031 (20.071; 0.132) 0.069 (20.047; 0.184)
LDL-C (mmol/L) 20.012 (20.185; 0.161) 20.106 (20.307; 0.095) 20.012 (20.185; 0.162) 0.074 (20.128; 0.275)
HDL-C (mmol/L) 20.017 (20.085; 0.050) 20.009 (20.092; 0.075) 20.003 (20.070; 0.065) 0.032 (20.054; 0.117)
FFA (mmol/L) 0.047 (20.001; 0.096) 0.080 (0.020; 0.140)** 0.022 (20.027; 0.070) 20.018 (20.079; 0.043)
Leptin 20.604 (22.925; 1.718) 20.499 (23.530; 2.532) 21.599 (23.927; 0.728) 21.332 (24.376; 1.712)
$Adjusted for baseline values of the outcome variable. $$Adjusted for baseline values of the outcome variable, maternal age, BMI at time
of examination, gestational week, insulin resistance at time of examination (HOMA index), self-reported food intake at time of
examination (portion size), self-reported PA, and maternal smoking. †Adjusted for sex and gestational week, except gestational week only
adjusted for sex. ††Adjusted for gestational age, maternal age, maternal pregestational BMI, maternal baseline lipid levels, and insulin resistance
(maternal HOMA index, fetal glucose/C-peptide ratio). All results shown without correction for multiple comparisons. *P , 0.05. **P , 0.01.
***P , 0.001.

gestation in the intervention group (25).
Another study comparing low glycemic
index versus low fat intake found a signif-
icant lower increase of cholesterol and TG
levels between baseline and 36 weeks
gestation in the low glycemic index group
(26).
Recent reports state that a reduction
in carbohydrate intake also creates a
risk of an unbalanced increase in fat
intake, which could increase FFA levels
and consequently induce IR and increase
maternal glucose levels (7,19). However,
in our study, we did not observe an
increased, but rather a significantly de-
creased, self-reported fat intake in HE
versus no HE at 24–28 weeks of gestation,
which was not associated with any of the
maternal lipid parameters, fasting glu-
cose, or gestational weight gain (data not
shown). The fiber intake patterns do not
suggest higher or lower diet quality in
one of the groups.
Studies performed in healthy non-
obese pregnant women (mean BMI ,25
kg/m2) show contrasting findings com-
pared with those studying obese
women. Significant decreases of TC
and LDL-C throughout pregnancy after
dietary intervention starting at 18 weeks
of gestation compared with usual diet
were reported (25). Contrary to our
results, women performing recreational
PA in early pregnancy had significantly
lower plasma TG levels than inactive
women (27). A linear correlation was
found showing lower concentrations of
TG and cholesterol across groups as
activity intensity increased. Another
trial investigating the effects of aerobic
exercise in the second half of pregnancy
in healthy women (mean BMI = 25.5
kg/m2) observed a trend toward lower
maternal FFA levels and significant in-
creases in leptin levels compared with
control subjects (28). We did not ob-
serve any differences in lipids in PA, which
might be due to low PA intensity in our
obese women.
Effects of Lifestyle Intervention on
Cord Blood Lipid Levels
FFAs are important for fetal deve-
lopment, and increased maternal FFAs
are associated with adverse pregnancy
and fetal outcomes (7,19). Literature
reports that FFAs are not transferred
across the placenta to a large extent
(9). It is speculated that the maternal
metabolic constitution directly affects
placental physiology and that placental
function and dysfunction are set or pro-
grammed very early in pregnancy (29).
Thus, the initiation of lifestyle interven-
tion close to 20 weeks of gestation might
be too late to affect maternal and neo-
natal metabolism significantly. Lifestyle
intervention and reduced weight gain
might act on placenta function, and re-
cently, potential beneficial changes by
intervention in placental lipid drop-
let composition were reported (30). How-
ever, in the control group (without
lifestyle intervention), higher dihomo-
ɣ-linolenic acid (DGLA) content was
detected. Interestingly, DGLA content in
placental lipid droplets was associated
with gestational weight gain, and prior
studies reported not only associations
between higher maternal DGLA levels
during pregnancy and maternal insulin
resistance and obesity but also positive
1388 DALIdLipids After Lifestyle Intervention
associations with adiposity measures in
early childhood (30–32). Thus, polyun-
saturated fatty acids and especially
DGLA may play a central role in the
development of the offspring. Placentas of
obese pregnant women store larger
amounts of lipid caused by increased
esterification, which might limit nutrient
transport to the fetus (33) and even
causes an upregulation of placental
genes involved in lipid storage and trans-
portation (34). A positive association of
neonatal birth weight and neonatal
adiposity with placental lipoprotein li-
pase (pLPL) activity, which hydrolyzes TG
into FFAs and facilitates transplacental
fatty acid transfer, was found recently
(35). Differences in pLPL activity influ-
enced by maternal metabolism might act
as a relevant placental mechanism in-
volved in fetal fat accumulation, which
highlights opportunities for future stud-
ies (35).
However, we are not able to explain
higher cord blood FFA levels and can only
speculate that higher FFA is either a re-
flection of higher IR in fetal tissue or
a response to higher catecholamines
due to increased fetal stress during de-
livery. However, we did not find differ-
ences in cord blood C-peptide levels or
area under the curve glucose/C-peptide
ratio (data not shown) between HE and no
HE, which are difficult to interpret anyway
in a nonfasted state at time of delivery.
Nonetheless, we could not find differ-
ences in cord blood FFA levels of PA
versus no PA groups either, which also
were exposed to the fetal stress at de-
livery. These interesting but unclear spec-
ulations require further studies.
Strengths and Limitations
Sample size calculation was based on
the primary outcome, and no formal
calculation of statistical power for this
secondary analysis was performed. The
original DALI design was as a 2 3 2 fac-
torial trial, and interaction was shown in
the analyses for the primary outcome
weight gain. Hence, each individual cell
was reported in the primary analysis. For
the lipid analyses, we have continued
with the factorial analysis. A positive
preselection might have occurred. Many
pregnant women willing to change their
lifestyle wanted to participate. This pos-
itive spirit of change might also have
affected the usual care group (Haw-
thorne effect), limiting the effects of
the lifestyle intervention groups. De-
creased participation of subjects at
high risk due to intervention-related re-
sponse bias needs to be considered.
Furthermore, we are not able to report
differences in specific FFAs or changes in
placenta physiology. Food intake and PA
were self-reported, which can result in
under- or overreporting due to social
desirability and recall bias. Additionally,
our food questionnaire does not allow
the calculation of detailed information of
macronutrient content but only gives
information about servings per week.
We are not able to quantify the degree
of carbohydrate restriction in numbers
(grams/day) due to the design of our
study. Our study aimed to deliver lifestyle
intervention messages (Supplementary
Table 1) built upon behavioral theory
principles (16) and included patient em-
powerment and cognitive behavioral
techniques inspired by motivational in-
terviewing (14,15) but was not based
on a predefined macronutrient distribu-
tion or strategy to install a low-carbo-
hydrate diet. Type of fat is important for
glucose homeostasis, and in our analysis
we have not addressed it. DALI included
only obese women; thus, no normal-
weight control group exists, and the
effects seen in our study do not imply
emergence in normal-weight pregnan-
cies, which needs to be tested. The
strengths of this study are that women
with hyperglycemia in early pregnancy
were excluded and we collected data on
dietary intake, different than many prior
studies performed.
Conclusion
The HE intervention, with significantly
lower gestational weight gain, resulted in
increased maternal FFA and 3BHB levels,
which suggests stimulation of maternal
lipolysis by the intervention. This might
have induced the increased fasting blood
glucose and may have worked against the
goal of preventing GDM. Even neonatal
FFAs in cord blood were significantly
higher after HE intervention. However,
the consequences of these changes are
unknown. In pregnancy, HE compared
with PA intervention is a powerful tool to
impact maternal and fetal metabolism.
This supports healthy nutrition for all
pregnant women, particularly for preg-
nancies at risk for fetal overgrowth.
However, further studies are needed
to test our hypothesis and to investigate
Diabetes Care Volume 42, August 2019
the long-term consequences in obese
women and their offspring.
Acknowledgments. The authors thank the
coaches, research midwives/nurses, and health
professionals collaborating in the recruitment.
The authors thank all women, their babies, and
families participating in the DALI trials. Finally, the
authors thank Andre von Assche (Development
and Regeneration, KU Leuven, University Leuven,
Leuven, Belgium) wholeheartedly, who contrib-
uted to the conception, design, and execution of
DALI but sadly died before submission. Rest in
peace.
Funding. The project described has received
funding from the European Community’s 7th
Framework Programme (FP7/2007-2013) under
grant agreement 242187. In the Netherlands,
additional funding was provided by the Nether-
lands Organisation for Health Research and De-
velopment (ZonMw) (grant 200310013). In the
U.K., the DALI team acknowledges the support
received from the National Institute for Health
Research Clinical Research Network: Eastern,
especially the local diabetes clinical and research
teams based in Cambridge. In Spain, additional
funding was provided by CAIBER 1527-B-226.
The funders had no role in any aspect of the
study beyond funding.
Duality of Interest. No potential conflicts of
interest relevant to this article were reported.
Author Contributions. J.H. wrote the manu-
script, performed the statistical analyses, and
edited and finalized the manuscript. J.H., D.S.,
G.D., R.C., J.M.A., R.D., S.G., P.D., E.R.M., D.M.J.,
L.L.T.A., F.D., A.L., M.G.D., A.B., E.W.-O., A.Z.,
U.M., D.H., J.G.M.J., F.J.S., M.L., C.L., C.W.,
D.B.-T., H.S., M.N.M.v.P., and A.K.-W. read
and corrected draft versions of the manuscript
and approved the final manuscript. J.H., S.G.,
D.M.J., L.L.T.A., M.G.D., A.B., A.Z., U.M.,
J.G.M.J., M.L., C.L., C.W., D.B.-T., and H.S. exe-
cuted DALI and provided input for the inter-
pretation of the results. D.S. was the study
coordinator. D.S., G.D., R.C., J.M.A., R.D., P.D.,
E.R.M., F.D., A.L., E.W.-O., D.H., F.J.S., M.N.M.v.P.,
and A.K.-W. designed and executed the DALI
study and provided input for the interpreta-
tion of the results. G.D. was the principal in-
vestigator of the study. M.N.M.v.P. was the
sponsor of the study. J.H. and A.K.-W. are the
guarantors of this work and, as such, had full
access to all the data in the study and take
responsibility for the integrity of the data and
the accuracy of the data analysis.
References
1. Geraghty AA, Alberdi G, O’Sullivan EJ, et al.
Maternal and fetal blood lipid concentrations
during pregnancy differ by maternal body mass
index: findings from the ROLO study. BMC Preg-
nancy Childbirth 2017;17:360
2. Catalano PM, Hauguel-De Mouzon S. Is it time
to revisit the Pedersen hypothesis in the face of
the obesity epidemic? Am J Obstet Gynecol
2011;204:479–487
3. Harreiter J, Simmons D, Desoye G, et al.; DALI
Core Investigator Group. IADPSG and WHO
2013 gestational diabetes mellitus criteria
care.diabetesjournals.org
identify obese women with marked insulin re-
sistance in early pregnancy. Diabetes Care 2016;
39:e90–e92
4. Poston L, Bell R, Croker H, et al.; UPBEAT Trial
Consortium. Effect of a behavioural intervention
in obese pregnant women (the UPBEAT study):
a multicentre, randomised controlled trial. Lan-
cet Diabetes Endocrinol 2015;3:767–777
5. Dodd JM, Turnbull D, McPhee AJ, et al.; LIMIT
Randomised Trial Group. Antenatal lifestyle advice
for women who are overweight or obese: LIMIT
randomised trial. BMJ 2014;348:g1285
6. Simmons D, Devlieger R, van Assche A, et al.
Effect of physical activity and/or healthy eating
on GDM risk: the DALI Lifestyle Study. J Clin
Endocrinol Metab 2017;102:903–913
7. Barbour LA, Hernandez TL. Maternal non-
glycemic contributors to fetal growth in obesity
and gestational diabetes: spotlight on lipids. Curr
Diab Rep 2018;18:37
8. Barrett HL, Dekker Nitert M, McIntyre HD,
Callaway LK. Normalizing metabolism in diabetic
pregnancy: is it time to target lipids? Diabetes
Care 2014;37:1484–1493
9. Herrera E, Ortega-Senovilla H. Maternal lipid
metabolism during normal pregnancy and its
implications to fetal development. Clin Lipidol
2010;5:899–911
10. Diderholm B, Stridsberg M, Ewald U,
Lindeberg-Nordén S, Gustafsson J. Increased
lipolysis in non-obese pregnant women studied
in the third trimester. BJOG 2005;112:713–718
11. Sivan E, Homko CJ, Chen X, Reece EA, Boden
G. Effect of insulin on fat metabolism during
and after normal pregnancy. Diabetes 1999;48:
834–838
12. Wild R, Weedin EA, Wilson D. Dyslipidemia
in pregnancy. Endocrinol Metab Clin North Am
2016;45:55–63
13. Nederlof M, de Walle HE, van Poppel MN,
Vrijkotte TG, Gademan MG. Deviant early preg-
nancy maternal triglyceride levels and increased
risk of congenital anomalies: a prospective
community-based cohort study. BJOG 2015;122:
1176–1183
14. Jelsma JG, van Poppel MN, Galjaard S, et al.
DALI: vitamin D and lifestyle intervention for
gestational diabetes mellitus (GDM) prevention:
an European multicentre, randomised trial -
study protocol. BMC Pregnancy Childbirth
2013;13:142
15. Simmons D, Jelsma JG, Galjaard S, et al.
Results from a European multicenter random-
ized trial of physical activity and/or healthy
eating to reduce the risk of gestational diabetes
mellitus: the DALI Lifestyle Pilot. Diabetes Care
2015;38:1650–1656
16. Miller WR, Rollnick S. Motivational Inter-
viewing, Preparing People to Change Addictive
Behavior. New York, The Guildford Press, 1991
17. Chasan-Taber L, Schmidt MD, Roberts DE,
Hosmer D, Markenson G, Freedson PS. Development
and validation of a Pregnancy Physical Activity
Questionnaire. Med Sci Sports Exerc 2004;36:
1750–1760
18. Simmons D, Mandell C, Fleming C, Gatland B,
Leakehe L. Evaluation of a diabetes knowledge
and behaviour (DKB) questionnaire. Asia Pac J
Clin Nutr 1994;3:193–200
19. Hernandez TL, Mande A, Barbour LA. Nutri-
tion therapy within and beyond gestational di-
abetes. Diabetes Res Clin Pract 2018;145:39–50
20. Hernandez TL, Van Pelt RE, Anderson MA,
et al. Women with gestational diabetes mellitus
randomized to a higher-complex carbohydrate/
low-fat diet manifest lower adipose tissue insulin
resistance, inflammation, glucose, and free fatty
acids: a pilot study. Diabetes Care 2016;39:39–42
21. Nolan CJ. Improved glucose tolerance in
gestational diabetic women on a low fat, high
unrefined carbohydrate diet. Aust N Z J Obstet
Gynaecol 1984;24:174–177
22. Moran LJ, Fraser LM, Sundernathan T, et al.
The effect of an antenatal lifestyle intervention
in overweight and obese women on circulating
cardiometabolic and inflammatory biomarkers:
secondary analyses from the LIMIT randomised
trial. BMC Med 2017;15:32
23. Vinter CA, Jørgensen JS, Ovesen P, Beck-
Nielsen H, Skytthe A, Jensen DM. Metabolic
effects of lifestyle intervention in obese pregnant
women. Results from the randomized controlled
trial ‘Lifestyle in Pregnancy’ (LiP). Diabet Med
2014;31:1323–1330
24. Renault KM, Carlsen EM, Hædersdal S, et al.
Impact of lifestyle intervention for obese women
during pregnancy on maternal metabolic and in-
flammatory markers. Int J Obes 2017;41:598–605
25. Khoury J, Henriksen T, Christophersen B,
Tonstad S. Effect of a cholesterol-lowering diet
on maternal, cord, and neonatal lipids, and
Harreiter and Associates 1389
pregnancy outcome: a randomized clinical trial.
Am J Obstet Gynecol 2005;193:1292–1301
26. Rhodes ET, Pawlak DB, Takoudes TC, et al.
Effects of a low-glycemic load diet in overweight
and obese pregnant women: a pilot randomized
controlled trial. Am J Clin Nutr 2010;92:1306–
1315
27. Butler CL, Williams MA, Sorensen TK,
Frederick IO, Leisenring WM. Relation between
maternal recreational physical activity and
plasma lipids in early pregnancy. Am J Epidemiol
2004;160:350–359
28. Hopkins SA, Baldi JC, Cutfield WS, McCowan
L, Hofman PL. Effects of exercise training on
maternal hormonal changes in pregnancy. Clin
Endocrinol (Oxf) 2011;74:495–500
29. Catalano P. Maternal pre-pregnancy BMI:
harbinger of late-pregnancy maternal lipid pro-
file. BJOG 2016;123:579
30. Gázquez A, Uhl O, Ruı́z-Palacios M, et al.;
UPBEAT Consortium. Placental lipid droplet
composition: effect of a lifestyle intervention
(UPBEAT) in obese pregnant women. Biochim
Biophys Acta Mol Cell Biol Lipids 2018;1863:
998–1005
31. Vidakovic AJ, Gishti O, Voortman T, et al.
Maternal plasma PUFA concentrations during
pregnancy and childhood adiposity: the Gener-
ation R Study. Am J Clin Nutr 2016;103:1017–
1025
32. de Vries PS, Gielen M, Rizopoulos D, et al.
Association between polyunsaturated fatty acid
concentrations in maternal plasma phospholi-
pids during pregnancy and offspring adiposity
at age 7: the MEFAB cohort. Prostaglandins
Leukot Essent Fatty Acids 2014;91:81–85
33. Calabuig-Navarro V, Haghiac M, Minium J,
et al. Effect of maternal obesity on placental
lipid metabolism. Endocrinology 2017;158:
2543–2555
34. Hirschmugl B, Desoye G, Catalano P, et al.
Maternal obesity modulates intracellular lipid
turnover in the human term placenta. Int J Obes
2017;41:317–323
35. Heerwagen MJR, Gumina DL, Hernandez TL,
et al. Placental lipoprotein lipase activity is
positively associated with newborn adiposity.
Placenta 2018;64:53–60