ARTICLE IN PRESS

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Journal of Sport and Health Science xxx (2019) xxx-xxx

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1 Original article 53
2 54
3 Associations of physical activity, sedentary time and physical fitness with 55
4 56
5 mental health during pregnancy: The GESTAFIT project 57
6 58
7
Q1 7X XMar

XD ıa Rodriguez-Ayllon D8X X *, D9X XPedro Acosta-Manzano D10X X , D1X XIrene Coll-Risco D12X X , D13X XLidia Romero-Gallardo D14X X ,
a, b c b
59
8 D15X XMilkana Borges-Cosic D16XbX , D17X XFernando Est
evez-L
D18X X , D19X XVirginia A. Aparicio cD20X X
opez b,d 60
a
9 PROFITH (PROmoting FITness and Health through Physical Activity) Research Group, Department of Physical Education and Sports, Faculty of Sport Sciences, 61
10 University of Granada, 18071 Granada, Spain 62
b
Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, 18071 Granada, Spain
11 c 63
Department of Physiology, Faculty of Pharmacy and Institute of Nutrition and Food Technology, University of Granada, 18011 Granada, Spain
12 d
Department of Psychology, Faculty of Social and Behavioural Sciences, Utrecht University, 3584 CS Utrecht, the Netherlands 64
13 65
Received 8 November 2018; revised 24 December 2018; accepted 11 March 2019
14 Available online xxx 66
15 67
16 68
17 69
Abstract
18 70
19 Purpose: To analyze the associations of objectively measured physical activity (PA), sedentary time and physical fitness with mental health in 71
20 the early second trimester (16 § 2 gestational weeks) of pregnancy. 72
21 Methods: From 229 women initially contacted, 124 pregnant women participated in the present cross-sectional study. Data were collected 73
22 between November 2015 and February 2017. The participants wore Triaxial accelerometers Actigraph GT3X+ accelerometers for 9 consecutive 74
23
days to objectively measure their PA behaviors and sedentary time. A performance-based test battery was used to measure physical fitness. Self- 75
report questionnaires assessed psychological ill-being (i.e., negative affect, anxiety, and depression), and psychological well-being (i.e., emo-
24 76
tional intelligence, resilience, positive affect). Linear regression analyses were adjusted for age, educational level, accelerometer wear time, mis-
25 77
carriages and low back pain.
26 78
Results: Moderate-to-vigorous PA was negatively associated with depression (b = 0.222; adjusted R2 = 0.050; p = 0.041). Higher levels of sed-
27 79
entary time were negatively associated with positive affect (b = 0.260; adjusted R2 = 0.085; p = 0.017). Greater upper-body flexibility was posi-
28 tively associated with better emotional regulation (b = 0.195; adjusted R2= 0.030; p = 0.047). The remaining associations were not significant (all 80
29 p > 0.05). 81
30 Conclusion: An active lifestyle characterized by higher levels of moderate-to-vigorous PA and lower levels of sedentary time during pregnancy 82
31 might modestly improve the mental health of pregnant women. Although previous research has focused on the benefits of cardiorespiratory exer- 83
32 cise, the present study shows that only upper-body flexibility is related to emotional regulation in early pregnant women. If the present findings 84
33 are corroborated in further experimental research, physical exercise programs should focus on enhancing flexibility to promote improvements in 85
34
emotional regulation during early second-trimester of pregnancy. 86
Ó 2019 Published by Elsevier B.V. on behalf of Shanghai University of Sport. This is an open access article under the CC BY-NC-ND license.
35 87
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
36 88
37 Keywords: ActiGraph GT3X; Emotional dysregulation; Psychological health; Sedentary behavior; Stretching 89
38 90
39 91
40 92
41 1. Introduction disorders.2 Indeed, 7% 15% of women during pregnancy are 93
42 affected by mental disorders.3 Mental disorders and poor men- 94
Pregnancy induces multiple physiologic changes affecting
43 tal health (also known as psychological ill-being, which 95
the maternalD21X X cardiovascular, hormonal, and metabolic sys-
44 involves unpleasant feelings or emotions that impact the level 96
tems.1 In addition, pregnancy is widely considered to be a
45 of functioning4,5) impose a negative burden on women during 97
period in a woman’s life of increased vulnerability to mental
46 pregnancy. For instance, anxiety and depression are related to 98
47 more severe nausea and vomiting, extended absences from 99
48 Peer review under responsibility of Shanghai University of Sport.
work, and increased visits to physicians during pregnancy.6 100
49 * Corresponding author. Higher levels of psychological ill-being during pregnancy are 101
50 E-mail address: rodriguezm@ugr.es (M. Rodriguez-Ayllon). also linked to adverse events during childbirth; women with 102
51 103
https://doi.org/10.1016/j.jshs.2019.04.003
52 2095-2546/Ó 2019 Published by Elsevier B.V. on behalf of Shanghai University of Sport. This is an open access article under the CC BY-NC-ND license. 104
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
2 M. Rodriguez-Ayllon et al.

105 high levels of anxiety during the first weeks of gestation have and physical fitness with psychological ill-being and well- 162
106 been shown to have a higher probability of suffering a miscar- being in the early second trimester of pregnancy. Based on 163
107 riage and have an increased risk of preterm delivery and cae- previous literature, we hypothesized that higher levels of PAD34X X 164
108 sarean section.7 and physical fitness would be related to better mental health in 165
109 According to the World Health Organization, mental health pregnancy. We expect increased levels of sedentary time 166
110 is “a state of well-being in which every individual realizes his would be related to a worseD35X X mental health in pregnant women. 167
111 or her own potential, can cope with the normal stresses of life, 168
112 can work productively and fruitfully, and is able to make a 2. Materials and Methods 169
113 contribution to her or his community.”D2X8X In this context, psy- 170
114 chological well-being is the combination of positive affective 2.1. Participants 171
115 states and functioning with optimal effectiveness in personal The present cross-sectional study was developed in Gran- 172
116 and social life.4,5 Therefore, mental health not only depends ada (southern Spain) within the D36X XGESTAtion and FITness 173
117 on the absence of psychological ill-being, but also on the pres- (GESTAFIT) project framework.22 For feasibility reasons, the 174
118 ence of psychological well-being. Interestingly, evidence sug- baseline data collection occurred in 2 waves between Novem- 175
119 gests that psychological well-being during pregnancy acts as a ber 2015 and March 2017. From the 229 pregnant women ini- 176
120 protective factor against mental disorders not only in the moth- tially contacted, 161 women in early pregnancy were recruited 177
121 ers,9 but also in their children.10 Despite substantial efforts in at their first visit to a hospital (typically during the 12th gesta- 178
122 the field, no effective interventions exist that substantially help tional week). Of the 161 women recruited at the first assess- 179
123 pregnant women to cope with the psychological impact that ment, a total of 37 were excluded either because they did not 180
124 the changes brought about by pregnancy have on women.11 meet the inclusion criteria (n = 2) or because they declined to 181
125 Thus, the search for readily modifiable intervention targets is participate (n = 35). Data for the remaining 124 participants 182
126 ongoing. In this context, more physical activity (PA), fewer (mean age, 32.9 § 4.7 yearsD37X X) were D38X Xincluded D39X Xin these analyses. 183
127 sedentary behaviors, D23X X and higher levels of physical fitness have A detailed description of the study design and methods has 184
128 been identified as promising targets not only for reducing psy- been published elsewhere.22 Briefly, the inclusion criteria 185
129 chological ill-being, but also for boosting psychological well- included the following: (i) participants answered “no” to all 186
130 being in the general population,12,13 which is desirable also for questions on the PARmed-X for pregnancy health checklist 187
131 maternal and D24X Xfetal health during pregnancy and later in life.14 and (ii) participants were able to walk without assistance, were 188
132 In the last few years, it has been suggested that D25X XPAD26X X (i.e., any able to read and write sufficiently (e.g., they do not need help 189
133 body movement that increases energy expenditure above the to fill out the questionnaires), and were willing and able to pro- 190
134 basal metabolic rate15) may be associated with better mental vide consent. The exclusion criteria included having an acute 191
135 health during pregnancy.16 18 Although inspiring, previous or terminal illness, malnutrition, the inability to participate in 192
136 research presents caveats. First, the assessment of PA has a physical fitness test, pregnancy risk factors, multiple preg- 193
137 relied on self-reports.16,17 Second, only psychological ill- nancies, chromosopathy or fetal malformations, uterine growth 194
138 being18 has been studied. Third, there are no previous studies restriction, an upper or lower extremity fracture in the past 3 195
139 testing the association of sedentary time (i.e., any waking months or registration in any other exercise program.22 196
140 D27X Xbehavior characterized
D28X X by an energy expenditure D29X X1.5 meta- The participants provided written informed consent before 197
141 bolic equivalents D30X Xwhile in a sitting, reclining, or lying pos- taking part in this study, which was approved by the Clinical 198
142 ture19) or physical fitness (i.e., a set of attributes that people Research Ethics Committee of Granada, Government of Anda- 199
143 have or achieve that relate to the ability to do physical activi- lusia, Spain (code: GESFIT-0448-N-15). The study was con- 200
144 ties15) with the mental health of pregnant women. Previous lit- ducted following the ethical guidelines of the Declaration of 201
145 erature has suggested that lower levels of sedentary time and Helsinki, last modified in 2013. 202
146 higher levels of physical fitness are related to worse mental 203
147 health in the general population,13,20 a relationship that 204
2.2. Procedures
148 remains to be corroborated in pregnant women. 205
149 To sum up, research that objectively measures PA (e.g., by After being contacted by the research team during their first 206
150 means of accelerometry) and considers not only psychological D40Xgynecological
X visit to the Hospital in their 12th gestational 207
151 ill-being, but also psychological well-being is required D31X Xto pro- week, participants were invited to carry out the study at the 208
152 vide robust evidence. The study of levels of sedentary time Sport and Health Research Centre, University of Granada, 209
153 (which along with PA occupies all the waking hours of a day) Spain. Data on the age, weight, height, and phone number of 210
154 may help us to better understand the relationship between participants were collected during their first visit to the hospi- 211
155 pregnant women’s behaviors D32X X and their levels of mental health. tal. During D41X Xgestational week 16 § 2, a first assessment was 212
156 Furthermore, taking into account pregnant women’s levels of conducted. The assessments were always conducted over 213
157 physical fitness (a robust physiological measure that reflects 1 day in the same order. First, each participant filled out an ini- 214
158 the amount of PA during the previous D3X X3 months21) may pro- tial self-report survey D42X Xto provide information on her sociode- 215
159 vide a more comprehensive picture of the associations under mographic and clinical characteristics. Second, each 216
160 study. Therefore, the aim of the present study was to analyze participant completed the mental health questionnaires (i.e., 217
161 the associations of objectively measured PA, sedentary time, the 10-item Connor-Davidson Resilience Scale, the Center for 218

Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
Physical activity, sedentary time, physical fitness, and mental health in pregnant women 3

219 Epidemiological StudiesD43X X Depression Scale (CES-D) ques- Positive affect and negative affect were assessed by the 276
220 tionnaire, the Positive and Negative Affect Schedule, State Trait Positive and Negative Affect Schedule.28 This question- 277
221 Trait Anxiety Index, and Trait Meta-Mood ScaleD4X X). Third, naire includes questions on 10 positive and 10 negative emo- 278
222 each participant performed the physical fitness tests (i.e., tional states that are answered on a 5-point Likert scale, from 279
223 back-scratch test, handgrip test, 6-min walk test). After- 1 D53X X(very slightly or not at all)D54X X to 5 D5X X(extremely)D56X X. Scores can range 280
224 wardD45X X, participants were asked to wear the accelerometers from 10 to 50 for both subscales (positive affect and negative 281
225 for 9 consecutive days. affect), and higher scores reflect greater affective well-being. 282
226 The scales have been shown to be highly internally consistent, 283
227 largely uncorrelated, and stable in a 2-month period in the 284
2.3. Outcomes
228 adult population.28 The time frame adopted was “in general” 285
229 We objectively assessed the PA and sedentary time using (i.e., participants were asked to report how they feel “in gen- 286
230 ActiGraph GT3X+ triaxial accelerometry (ActiGraph, Pensa- eral, that is, on the average”). 287
231 cola, FL, USA), with an epoch length of 60 sec and a fre- Anxiety levels were assessed with the State Trait Anxiety 288
232 quency rate of 30 Hz. This method has previously been used IndexD.57X X 29 The total score ranges from 20 to 80, with higher val- 289
233 in pregnancy studies, and the methodology followed in the ues indicating greater levels of anxiety. The State Trait Anxi- 290
234 present study was similar to the one used in previous studies.23 ety IndexD58X X is one of the most commonly validated self-report 291
235 The participants wore the accelerometer on their waist for 9 questionnaires usedD59X X to evaluate anxiety in pregnant women.29 292
236 consecutive days, 24 h/day, except during water-based activi- To measure trait (dispositional) anxiety, participants answer 293
237 ties. Participants had to have data for a total of 7 days of wear- questions such as, “How do you usually feel?” 294
238 ing time (5 weekdays and 2 weekend days) with a minimum of Pregnant antenatal depression among the participants was 295
239 D46X X10 h per waking hD47X X/day to be included in the analyses. The assessed using the D60X XCES-DD61X X. The revised CES-D, which includes 296
240 accelerometer wearing time was calculated by deducting the 35 items, was usedD62X X. However, we calculated the overall score 297
241 sleeping time and the non-wear time from the total time regis- using only 20 items D63X Xbecause this is the most accepted calcula- 298
242 tered for the whole day. Recordings with values of tion method across the literature. The CES-D has been vali- 299
243 20,000 counts/min were excluded because of potential mal- dated and is widely D64X Xused in pregnancy studies.30 In regard to 300
244 function. We also excluded from the analyses all 90-min bouts reliability, Chronbach’s a was 0.90, with similar coefficients 301
245 with 0 activity intensity counts. The time involved in bouted by groups of age and sex and by interviewer.30 The CES-D 302
246 moderate-to-vigorous PA D48X X (MVPA) (periods of D49X X10 continuous uses the D65X Xlast 7 daysD6X X as the time frame. 303
247 min of MVPA) was calculated based on a PA recommended The Trait Meta-Mood ScaleD31 67X X D68X Xincludes 3 subscales to assess 304
248 vector magnitude cut point of D50X X2690 counts/min (up to 2 min participants’ beliefs about attending to and valuing their feel- 305
249 below the cut point allowance), and it was expressed in min/ ings (emotional attention), feeling clear rather than confused 306
250 week.24 Sedentary time was calculated as the amount of time about their feelings (emotional clarity), and the degree to 307
251 accumulated below 200 counts/min and was expressed in min/ which they regulate their moods and repair negative emotional 308
252 day.25 The data download, reduction, cleaning, and analyses experiences (emotional regulation). Each subscale D69X Xincludes 8 309
253 were performed using ActiGraph software (ActiLife Version. items. The participants rate their responses using a 5-point 310
254 6.11.9; Actigraph). Of the 124 remaining participants, 22 were Likert-type scale, ranging from (D70X Xstrongly disagree)D71X X to 5 311
255 excluded because they did not wear the accelerometer (n = 5), D72X X(strongly agree)D73X X. The subscales’ scores range from 8 to 40, 312
256 they had incorrect data D51X Xowing to accelerometer malfunction where higher scores reflect greater attention, clarity, and regu- 313
257 (n = 5), or they did not have enough wearing days and/or hours lation. The Spanish modified version of the Trait Meta-Mood 314
258 (n = 12). The accelerometry data of the remaining 102 partici- ScaleD74X X had appropriate reliability and has been shown to be 315
259 pants were analyzed. valid.31 Participants were asked to use an “in general” time 316
260 We evaluated upper-body flexibility by the back-scratch frame. 317
261 test, a measure of overall shoulder range of motion. The dis- The 10-item Connor-Davidson Resilience Scale assesses 318
262 tance between (or overlap of) the middle fingers behind the resilience to stress.32 This construct refers to a dynamic pro- 319
263 back was measured with a ruler.26 The best score of 2 trials for cess of positive adaptation to adverse changes in life circum- 320
264 each arm was recorded, and the average of both arms was used stances. Each item’s score ranges from 0 D75X X(not true at all)D76X X to 4 D7X X 321
265 for the analyses. Upper-body muscular strength was evaluated (true nearly all the time)D.78X X The total score ranges from 0 to 40, 322
266 by handgrip strength, as described elsewhere.27 The partici- and higher scores indicate greater resilience. The Spanish ver- 323
267 pants performed the handgrip strength test twice, alternately sion of the 10-item Connor-Davidson Resilience Scale showed 324
268 with both hands, using a digital dynamometer (TKK 5101 good psychometric properties in young adults; thus, it is a reli- 325
269 Grip-D; Takey, Tokyo, Japan). The best value of D52X X2 attempts able and valid instrument for measuring resilience.32 Partici- 326
270 for each hand was recorded, and the average of both hands pants were asked to use an “in general” time frame. 327
271 was used in the analyses. An initial self-report survey was used to collect sociodemo- 328
272 We assessed cardiorespiratory fitness by the 6-min walk graphic and clinical data, D79X Xsuch as, age, educational level D80X X(low 329
273 test.26 In this test, the maximum distance (in meters) each par- educational (primary or highD81X X school), medium educational 330
274 ticipant could walk during 6 min along a 45.7-m rectangular level (professional training) and high educational level (uni- 331
275 course was recorded.26 versities studies)), and number of miscarriages. Fully trained 332

Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
4 M. Rodriguez-Ayllon et al.

333 researchers provided the participants with continuous instruc- Table 1 390
334 tions on how to complete the self-report. Additionally, lowD82X X Sociodemographic and clinical characteristics of the study participants. 391
335 back pain was assessed using the Pain Visual Analogue Scale. n Mean SD 392
336 This score is determined by measuring the distance (mm) on 393
Age (yD)1X X 124 32.9 4.7
337 the 10-cm line between the “no pain” anchor and the partic- LowD2X bX ack pain (VAS) 122 26.7 25.5 394
338 ipant’s mark, providing a range of scores from 0 to 100. Body Body mass index (kg/m2) 121 24.9 4.0 395
339 weight and height were measured while participants were in Educational level (%) 396
340 their bare feet and wearing underclothes. Weight (Din 83X X kilo- Low educational level 13 10.5 397
Medium educational level 41 33.1
341 grams) was measured with an electronic scale (SECA 861, 398
High educational level 70 56.4
342 Seca Ltd., Hamburg, Germany), and height (D84X Xin centimeters) Number of miscarriages (%) 399
343 was measured with a stadiometer (SECA 225, Seca Ltd.). 1 37 29.8 400
344 Body mass index was expressed as D85X Xkilograms per square 2 9 7.3 401
345 meter. 3 2 1.6 402
PAD3X aX nd sedentary time
346 403
Accelerometer wear time (min/week) 102 6607.5 372.0
347 D4X X PAD
MVD 5X X 6X (X min/week) 102 13.3 16.1 404
2.4. Data analysis
348 Sedentary time (min/day) 102 3588.6 677.0 405
349 All analyses were performed using the Statistical Package Physical fitness components 406
350 for Social Sciences (IBM SPSS Statistics for Windows, Ver- Upper-body flexibility (cm) 120 3.4 6.6 407
Upper-body muscular strength (kg) 120 26.7 4.9
351 sion 22.0; Armonk, NY, USAD86X X; with a pvalue set at < 0.05). 408
Cardiorespiratory fitness (m) 64 606.7 48.2
352 Descriptive statistics (mean § SD) for quantitative variables Psychological ill-being, mean (SD) 409
353 and number of women (%) for categorical variables) were usedD87X X Negative affect (PANAS-T) 109 17.8 6.1 410
354 to describe the baseline characteristics of the participants. Anxiety (STAI-T) 64 25.3 3.5 411
355 FirstD,8X X we explored the association of the potential confounders Depression (CES-D) 120 11.6 8.6 412
Psychological well-being
356 (e.g., body mass index) with the mental health outcomes. 413
Emotional attention (TMMS-A) 115 25.3 6.3
357 Number of miscarriages and low backD89X X pain were the 2 most Emotional clarity (TMMS-C) 116 30.6 5.0 414
358 strongly correlated confounders to the mental health outcomes. Emotional regulation (TMMS-R) 116 29.8 5.5 415
359 We conducted multiple linear regression analyses with PA, Resilience (CD-RISC) 113 29.9 5.4 416
360 sedentary time, and physical fitness measures as independent Positive affect (PANAS-T) 109 33.6 6.7 417
361 variables (predictors) and mental health components (i.e., psy- Notes: The data are shown as mean and unless otherwise indicated. MVPA is 418
362 chological well-being and psychological ill-being) as depen- based on periods of 10 continuous min of MVPA. Cardiorespiratory fitness 419
and anxiety were evaluated only during the first wave (n = 64). Body mass
363 dent variables (outcomes). Each set separately examined the 420
index was assessed during the 16th § 2 gestational week, as were the rest of
364 relationships between 1 predictor and 1 mental health out- the variables. Low educational level = primary or high-school. Medium educa- 421
365 come. The linear regression analyses were hierarchically tional level = professional training. High educational level = university studies. 422
366 adjusted for 2 different groups of confounders. Model 1 Abbreviations: SD = standard deviation; VAS = visual analogue scale; 423
367 included age, educational level, and accelerometer wear time PA = physical activity; MVPA = moderate-to-vigorous physical activity; 424
PANAS-T = The Positive and Negative Affect Schedule-Trait; STAI-T = the
368 (only in the case of PA and sedentary time variables). Model 2 425
State Trait Anxiety Index-Trait; CES-D = the Center for Epidemiological Stud-
369 was additionally adjusted for number of miscarriages and low ies-Depression Scale questionnaire; TMMS-A = The Trait Meta-Mood Scale- 426
370 backD90X X pain. Emotional Attention; TMMS-C = The Trait Meta-Mood Scale-Emotional Clar- 427
371 ity; TMMS-R = The Trait Meta-Mood Scale-Emotional Regulation; CD- 428
372 RISC = The 10-item Connor-Davidson Resilience Scale. 429
3. Results
373 430
374 The descriptive characteristics of the final study sample are not shown). No associations were found with the rest of the 431
375 presented in Table 1. Briefly, 29.8% of the pregnant women psychological ill-being outcomes (allD9X X p > 0.05). 432
376 had D91X X1 miscarriage in the past. Additionally, it was found that The associations found between PA, sedentary time, and 433
377 56.4% of the women had a high educational level. Briefly, physical fitness and psychological well-being indicators (i.e., 434
378 these results remained similar when only participants with no emotion regulation, resilience and positive affect) are shown 435
379 missing data were analyzed (n = 51). in Table 3. Sedentary time was inversely associated with posi- 436
380 Associations of PA, sedentary time, and physical fitness tive affect (b = 0.255;D10X X adjusted R2 = 0.019;D10X X p = 0.022) when 437
381 with psychological ill-being indicators (i.e., negative affect, the model was adjusted for age, educational level and acceler- 438
382 anxiety and depression) are shown in Table 2. MVPA was ometer wear time (D102X Xmodel 1). Subsequently, when the number 439
383 inversely associated with depression (b = 0.227D92X X; adjusted of miscarriages and low backD103X X pain were added to the model 440
384 R2 = 0.060;D93X X p = 0.035) when the model was adjusted for age, (D104X Xmodel 2), the association remained statistically significant 441
385 educational level, and accelerometer wear time (mD94X Xodel 1). (b = 0.260;D105X X adjusted R2 = 0.085;D106X X p = 0.017). The results were 442
386 After performing the analysis with mD95X Xodel 2, the association virtually the same when sedentary time (mD107X Xodel 2) was addi- 443
387 remained significant (b = 0.222;D96X X adjusted R2 = 0.050;D97X X tionally adjusted for MVPA (data not shown). Upper-body 444
388 p = 0.041). The results were virtually the same when MVPA flexibility was positively associated with emotional regulation 445
389 (in mD98X Xodel 2) was additionally adjusted for sedentary time (data (b = 0.195;D108X X adjusted R2 = 0.030;D109X X p = 0.047) when the model 446

Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
Physical activity, sedentary time, physical fitness, and mental health in pregnant women 5

447 Table 2 504

448 Associations of PA, sedentary time, and physical fitness with psychological ill-being in early pregnant women. 505
449 Negative Affect (PANAS-T) Anxiety (STAI-T) Depression (CES-D) 506
450 507
b p b p b p
451 508
452 MVPA (min/week) 509
Model 1 0.051 0.662 0.083 0.593 0.227 0.035
453 510
Model 2 0.040 0.731 0.041 0.793 0.222 0.041
454 Sedentary time (min/day) 511
455 Model 1 0.191 0.088 0.106 0.478 0.159 0.143 512
456 Model 2 0.200 0.080 0.068 0.654 0.166 0.135 513
457 Upper-body flexibility (cm) 514
Model 1 0.051 0.623 0.126 0.359 0.057 0.564
458 515
Model 2 0.055 0.597 0.107 0.445 0.064 0.515
459 Upper-body muscular strength (kg) 516
460 Model 1 0.059 0.563 0.178 0.189 0.107 0.262 517
461 Model 2 0.053 0.600 0.159 0.249 0.094 0.324 518
462 Cardiorespiratory fitness (m) 519
Model 1 0.146 0.318 0.075 0.603 0.076 0.590
463 520
Model 2 0.019 0.908 0.052 0.760 0.072 0.653
464 521
Notes: b Values are standardized regression coefficients. MVPA is based on periods of 10 continuous minutes of MVPA. Model 1 included age, educational level,
465 522
and accelerometer wear time (only in the case of the PA and sedentary time variables). Model 2 was additionally adjusted for number of miscarriages and low back
466 523
pain.
467 Statistically significant values are shown in bold. 524
468 Abbreviations: PA = physical activity; PANAS-T = The Positive and Negative Affect Schedule-trait; STAI-T= the State Trait Anxiety Index-trait; CES-D = the 525
469 Center for Epidemiological Studies-Depression Scale questionnaire; MVPA = moderate-to-vigorous physical activity. 526
470 527
471 528
472 was additionally adjusted by number of miscarriages and low association did not emerge.35 Similarly, a longitudinal study 529
473 backD10X X pain (D1X Xmodel 2). No associations were observed for the of pregnant women found that higher baseline MVPA (i.e., 530
474 rest of the psychological well-being outcomes (allD12X X p > 0.050). 17 22 weeks ofD15X X gestation) predicted lower depressive symp- 531
475 toms in the 24 29 weeks ofD16X X gestation.14 This result14 may be 532
476 explained by the fact that MVPA might have a positive impact 533
4. Discussion
477 on depression by increasing endorphin levels and modulating 534
478 The aim of the present study was to analyze the associations the response to stress on the D17X Xhypothalamic pituitaryD18X X adrenal 535
479 between objectively measured PA, sedentary time, and physi- axis.36 536
480 cal fitness and psychological ill-being and well-being in the A literature review suggests that pregnant women who 537
481 early second trimester of pregnancy. The present study indi- more frequently engage in PA experience lower anxiety and 538
482 cated that higher MVPA and lower sedentary time were mod- mood disorders during pregnancy,17,18 which was not corrobo- 539
483 estly associated with lower depressive symptoms and higher rated in the present study. A plausible explanation for this dis- 540
484 positive affect, respectively, in the early second trimester of crepancy might lie in the fact that the present study and other 541
485 pregnancy. Furthermore, upper-body flexibility was positively studies usedD19X X different approaches to evaluate PA: accelerome- 542
486 associated with emotional regulation. Upper-body muscular ters in the present study (i.e., an objective measure) and self- 543
487 strength and cardiorespiratory fitness were not related to men- reports in other studies (i.e., a subjective assessment).17 For 544
488 tal health. instance, previous studies have suggested that using methods 545
489 In line with the pregnancy literature,16,17 the findings in the with lower accuracy for assessing PA (i.e., self-reports) often 546
490 present study suggest that higher MVPA is associated with result in an overestimate of the time that a person engages in 547
491 lower depressive symptoms in pregnant women. The cross- PA and tend to produce higher (potentially inflated) effect 548
492 sectional design of the present study does not allow us to rule sizes when associations with health outcomes are tested.37 549
493 out the possibility of a bidirectional association between Another possible explanation for the null findings might be 550
494 MVPA and depressive symptoms in pregnancy, an association that pregnant women in our sample experienced low levels of 551
495 that remains unclear in the literature. For instance, another anxiety. Given that symptoms of anxiety fluctuate over the 552
496 cross-sectional study found that obese pregnant women with pregnancy (i.e., the D120X Xgreatest anxiety is often experienced dur- 553
497 lower depressive symptoms spent 85% more time in MVPA ing the first and last trimesters38), further research in the sec- 554
498 compared withD13X X women with higher depressed mood.33 Other ond trimester of pregnancy is warranted to corroborate our 555
499 studies found that a lack of motivation or self-confidence was findings. 556
500 related to a worse attitude toward PA.34 Interestingly, a 2-sam- In the present study, MVPA was not associated with psy- 557
501 ple Mendelian randomization study observed that, in the gen- chological well-being during pregnancy. Although MVPA 558
502 eral population, higher baseline MVPA was associated with often boosts psychological well-being,12 it also might have 559
503 lower depressive symptoms over time, althoughD14X X the reverse negative effects on psychological well-being in certain 560

Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
6 M. Rodriguez-Ayllon et al.

Notes: b Values are standardized regression coefficients. MVPA is based on periods of at least 10 continuous minutes of MVPA. Model 1 included age, educational level, and accelerometer wear time (only in the

Abbreviations: PA = physical activity; TMMS-A = The Trait Meta-Mood Scale-Emotional Attention; TMMS-C = The Trait Meta-Mood Scale-Emotional Clarity; TMMS-R = The Trait Meta-Mood Scale-Emotional
39
561 contexts and circumstances. For instance, when people do 618
562 not experience increased physical competence or perceived 619
Positive Affect (PANAS-T)

0.657
0.788

0.022
0.017

0.310
0.273

0.310
0.341

0.061
0.641
563 appearance (e.g., by not gaining strength, not experiencing 620
p

564 weight loss, or losing games all the time), PA has a negative 621
565 influence on physical self-concept, which in turn may impact 622
566 negatively on psychological well-being.39 Therefore, a possi- 623
567 ble explanation for our nonD12X Xsignificant findings may be that 624
0.052
0.030

0.255
0.260

0.105
0.110

0.102
0.093

0.274
0.074
568 changes in perceived appearance40 and perceived compe- 625

Regulation; CD-RISC = The 10-item Connor-Davidson Resilience Scale; PANAS-T = The Positive and Negative Affect Schedule-trait; MVPA = moderate-to-vigorous physical activity.
569 tence41 during pregnancy might mediate the positive role that 626
b

570 MVPA usually plays in psychological well-being. 627

571 D12X X
It is well-known that increased levels of sedentary time dur- 628
572 ing pregnancy are associated with poorer physical health, for 629
0.806
0.848

0.797
0.819

0.403
0.385

0.544
0.527

0.499
0.786
Resilience (CD-RISC)

573 exampleD123X X, the development of cardiometabolic complications.42 630

p

574 However, there is little knowledge about the association 631

575 between sedentary time and mental health during pregnancy.42 632
576 In the present study, sedentary time was inversely associated 633
577 with positive affect among women in the early second trimes- 634
0.027
0.021

0.028
0.026

0.085
0.089

0.060
0.062

0.095
0.045

578 ter of their pregnancies. No statistically significant results 635

b

579 were obtained for the remaining mental health outcomes. Posi- 636
580 tive affect may buffer against the harmful consequences of 637
581 exposure to a challenging life event such as pregnancy.43 A 638
Emotional Regulation (TMMS-R)

582 possible mechanism for explaining this might be that seden- 639
0.220
0.257

0.725
0.845

0.065
0.047

0.883
0.960

0.110
0.435

583 tary activities (such as lying on the couch) can limit social 640
case of the PA and sedentary time variables). Model 2 was additionally adjusted for number of miscarriages and low back pain.

584 interaction with others, which in turn can limit the possibilities 641
p

585 of having positive emotional experiences.44 642

586 The current study found that better upper-body flexibility 643
587 was associated with better emotional regulation (i.e., how well 644
Associations of PA, sedentary time, and physical fitness with psychological well-being in early pregnant women.

588 moods are regulated and negative emotional experiences are 645
0.136
0.125

0.039
0.022

0.180
0.195

0.014
0.005

0.224
0.124

589 repaired). To the best of our knowledge, the association 646

590 between flexibility and psychological well-being indicators in 647
b

591 pregnant women has not been explored previouslyD124X X. Conse- 648
592 quently, although direct comparisons with other studies cannot 649
593 be made, we speculate that changes in levels of relaxin, which 650
Emotional Clarity (TMMS-C)

594 is a neuropeptide that increases during pregnancy and is 651

0.958
0.836

0.927
0.756

0.154
0.102

0.764
0.861

0.198
0.520

595 related to D125X Xgreater flexibility in joints and tissue, might be a pos- 652
p

596 sible physiological mechanism that explains our finding.45 It 653

597 has recently been suggested that relaxin is involved in regulat- 654
598 ing aspects of physiological and D126X Xbehavioral stress responses 655
599 and the integration of sensory inputs.46 Therefore, relaxin may 656
0.006
0.023

0.010
0.035

0.141
0.161

0.029
0.017

0.182
0.100

600 be a physiological mechanism that explains why flexibility is 657

601 related to better emotional regulation during pregnancy. In 658
b

602 line with findings from other studies, flexibility seems to be a 659
603 key player in the successful appraisal of stress, especially 660
604 when stress is hardly avoidable, such as during pregnancy or 661
Statistically significant values are shown in bold.
Emotional Attention (TMMS-A)

605 chronic pain, and is consequently related to better mental 662

0.747
0.742

0.214
0.200

0.497
0.454

0.246
0.217

0.831
0.621

606 health.47 Surprisingly, aD127X Xlthough muscular strength and cardio- 663
p

607 respiratory fitness are widely recognized as protectors of phys- 664

608 ical health (e.g., abdominal adiposity, cardiovascular disease 665
Upper-body muscular strength (kg)

609 events, or skeletal health),13 they were not related to mental 666
Cardiorespiratory fitness (m)

610 health outcomes in the present study. Because this study is, to 667
Upper-body flexibility (cm)
Sedentary time (min/day)

611 the best of our knowledge, the first to analyze the association 668
0.068
0.076

0.112
0.120

0.030
0.036
0.037

0.138
0.147

0.080

612 of physical fitness with mental health in pregnant women, it is 669

MVPA (min/week)
b

613 not possible to compare our results with previous studies. 670
614 Thus, it is important to conduct observational studies and other 671
Model 1
Model 2

Model 1
Model 2

Model 1
Model 2

Model 1
Model 2

Model 1
Model 2

615 research in this area. Consequently, if the present findings are 672
Table 3

616 corroborated in further experimental research, physical exer- 673

617 cise programs might be developed to focus on enhancing 674

Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
 ARTICLE IN PRESS
Physical activity, sedentary time, physical fitness, and mental health in pregnant women 7

675 flexibility D128X Xto promote improvements in emotional regulation Granada, Plan Propio de Investigaci
on 2016, Excellence 732
676 during pregnancy. actions: Units of Excellence; Unit of Excellence on Exercise 733
677 Our study has several limitations. First, given the cross-sec- and Health (UCEES). Maria Rodriguez-Ayllon was supported 734
678 tional design of the present study, future longitudinal and by a grant from the Vice-Rectorate for Research and Knowl- 735
679 experimental research is warranted D129X Xto address the causality of edge Transfer from the University of Granada (Spain). Irene 736
680 our findings. Second, the missing data in our study D130X Xare another Coll-Risco and Milkana Borges-Cosic were supported by the 737
681 limitation, despite the fact that similar dropD13X Xout rates have Spanish Ministry of Education (Grant No.FPU14/02518 and 738
682 occurred in other studies of pregnant women.23,33 Third, FPU13/01993, respectively). Fernando Est
evez-L
opez was 739
683 although the questionnaires used to assess mental health and supported by the Spanish Ministry of Economy and Competi- 740
684 the physical fitness tests in this study were valid and reliable tiveness (Grant No.BES-2014-067612). We are grateful to Ms. 741
685 for the general population, their psychometric properties have Carmen Sainz Quinn for English-language assistance. 742
686 not been extensively tested among pregnant women, except 743
687 for the State Trait Anxiety IndexD132X X, whose validity has been pre- Authors’ contributions 744
688 viously corroborated at this stage of a woman’s life.29 Fourth, 745
689 psychological ill-being and well-being indicators were only MRA had full access to all of the data in the study, takes 746
690 reported during the second trimester of pregnancy. Given that responsibility for the integrity of the data and the accuracy of 747
691 psychological ill-being fluctuates during pregnancy, our find- the data analyses, conceptualized and designed the study, 748
692 ings are not generalizable to the first and third trimesters of interpreted the data, collected data, and drafted the initial man- 749
693 pregnancy. Fifth, the effect sizes for the association of PA, uscript. PAM conceptualized and designed the study, inter- 750
694 sedentary time and physical fitness with mental health seem to preted the data, and collected data. ICR conceptualized and 751
695 be small. To date, however, there is no well-established cutD13X Xoff designed the study, interpreted the data, and collected data. 752
696 point for evaluating the clinical relevance of effect sizes in the LRG conceptualized and designed the study, interpreted the 753
697 context of mental health. Finally, the difference in the time data, and collected data. MBC conceptualized and designed 754
698 frame for obtaining the accelerometry data and the mental the study, interpreted the data, and collected data. FEL concep- 755
699 health measures was approximately 1 week. tualized and designed the study, and interpreted the data. VAA 756
700 Despite these limitations, our present study has several conceptualized and designed the study, and interpreted the 757
701 strengths. First, we used objective measurements of PA, seden- data. All authors were involved in drafting the article and 758
702 tary time, and physical fitness. Additionally, we studied not revising it for important intellectual content. All authors have 759
703 only psychological ill-being, but also psychological well- read and approved the final version of the manuscript, and 760
704 being, which provides a more comprehensive understanding of agree with the order of presentation of the authors. 761
705 mental health among pregnant women. 762
706 Competing interests 763
707 5. Conclusion 764
The authors declare that they have no competing interests.
708 765
This study has shown that greater MVPA and lower levels
709 766
of sedentary time were modestly associated with less depres- Supplementary materials
710 767
sive symptoms and better positive affect, respectively. Further-
711 Supplementary material associated with this article can be 768
more, better upper-body flexibility was related to better
712 found in the online version at doi:10.1016/j.jshs.2019.04.003. 769
emotional regulation. If the present findings are corroborated
713 770
in further experimental research, an active lifestyle character-
714 771
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project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003
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Please cite this article as: Mar
ıa Rodriguez-Ayllon et al., Associations of physical activity, sedentary time and physical fitness with mental health during pregnancy: The GESTAFIT
project, Journal of Sport and Health Science (2019), https://doi.org/10.1016/j.jshs.2019.04.003