{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T19:17:36Z","timestamp":1787944656579,"version":"build-2784847793"},"reference-count":161,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Maternal overweight and obesity are increasing in Libya, yet multicity evidence among pregnant women remains limited, particularly regarding central adiposity and associations with socioeconomic characteristics, unhealthy eating behaviours (UEBs), physical inactivity, and sedentary behaviour. This study estimated the prevalence of women meeting standard WHO BMI cut-offs for overweight\/obesity at antenatal assessment and examined associated socioeconomic, dietary, and lifestyle characteristics among women attending participating public antenatal clinics in six Eastern Libyan cities. Methods: This cross-sectional study included 3000 pregnant women attending participating public antenatal clinics in six Eastern Libyan cities. A multistage, city-stratified sampling strategy was used. Participants completed a structured Arabic questionnaire assessing socioeconomic characteristics, dietary intake, physical inactivity, and sedentary behaviour. Trained female nurses obtained standardised anthropometric measurements during antenatal assessment using the TANITA RD-545HR Smart Segmental Body Composition Analyser. Body mass index (BMI) was evaluated as an indicator of general pregnancy-period adiposity, while WC and BIA-derived visceral fat rating (VFR) were treated as complementary epidemiological indicators rather than precise or diagnostic measures of visceral adiposity. For each participant, BMI, WC, and VFR were obtained during the same antenatal assessment; however, participants were recruited across different gestational stages. Multivariable linear regression examined associations between the specified exposures and continuous adiposity measures, while modified Poisson regression with robust variance estimated adjusted prevalence ratios (aPRs) for overweight\/obesity after adjustment for age, parity, gestational stage, and relevant covariates. Results: Among the recruited antenatal clinic sample, 60.6% had BMI-defined overweight\/obesity (95% CI: 58.9\u201362.3); using prespecified descriptive thresholds, 58.9% had WC \u2265 88 cm (95% CI: 57.1\u201360.7) and 52.1% had BIA-derived VFR \u2265 10 (95% CI: 50.3\u201353.9). Lower educational attainment (aPR = 1.24, 95% CI: 1.15\u20131.35, p &lt; 0.001) and lower household income (aPR = 1.18, 95% CI: 1.09\u20131.27, p = 0.004) were independently associated with a higher prevalence of overweight\/obesity. In the primary scale-level analyses, higher physical inactivity sedentary lifestyle scores (aPR = 1.04, 95% CI: 1.03\u20131.05, p &lt; 0.001) and higher UEBs scores (aPR = 1.07, 95% CI: 1.05\u20131.09, p &lt; 0.001) were associated with a higher prevalence of BMI-defined overweight\/obesity. In secondary exploratory item-level analyses, prolonged mobile phone use showed the strongest lifestyle association (aPR = 1.30, 95% CI: 1.20\u20131.41, p &lt; 0.001), while consuming fewer than five daily portions of fruit and vegetables demonstrated the strongest dietary association (aPR = 1.36, 95% CI: 1.24\u20131.49, p = 0.003). The full adjusted models accounted for 6.4\u201317.6% of variance in the continuous adiposity measures, indicating limited-to-modest explanatory power. Conclusions: BMI-defined weight status and elevated pregnancy-period adiposity indicators were common among women attending participating public antenatal services across six Eastern Libyan cities and were associated with socioeconomic disadvantage, sedentary behaviour, and poorer diet quality. The BMI-based classification reflects weight status at antenatal assessment and should not be interpreted as pre-pregnancy overweight\/obesity prevalence.<\/jats:p>","DOI":"10.3390\/nu18172828","type":"journal-article","created":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T18:33:52Z","timestamp":1787942032000},"page":"2828","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Maternal Adiposity in Eastern Libya: Prevalence and Associations with Socioeconomic Characteristics, Unhealthy Eating Behaviours, Physical Inactivity, and Sedentary Behaviour Among Pregnant Women"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8864-9223","authenticated-orcid":false,"given":"Hamdi","family":"Lemamsha","sequence":"first","affiliation":[{"name":"Faculty of Health Sciences, University of Tobruk, 2 Alhoria Road, Tobruk T14 H12, Libya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2289-5859","authenticated-orcid":false,"given":"Gurch","family":"Randhawa","sequence":"additional","affiliation":[{"name":"Institute for Health Research, University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton LU2 8LE, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2207","DOI":"10.1001\/jama.2017.3635","article-title":"Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis","volume":"317","author":"Goldstein","year":"2017","journal-title":"JAMA"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Kalantari, E., Tajvar, M., Naderimagham, S., and Takian, A. (2024). Maternal obesity management: A narrative literature review of health policies. BMC Women\u2019s Health, 24.","DOI":"10.1186\/s12905-024-03342-2"},{"key":"ref_3","first-page":"2401","article-title":"Global trends in prevalence of maternal overweight and obesity: A systematic review and meta-analysis of routinely collected data retrospective cohorts","volume":"9","author":"Kent","year":"2024","journal-title":"Int. J. Popul. Data Sci."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Voerman, E., Santos, S., Patro Golab, B., Amiano, P., Ballester, F., Barros, H., Bergstr\u00f6m, A., Charles, M.-A., Chatzi, L., and Chevrier, C. (2019). Maternal body mass index, gestational weight gain, and the risk of overweight and obesity across childhood: An individual participant data meta-analysis. PLoS Med., 16.","DOI":"10.1371\/journal.pmed.1002744"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1111\/nbu.70016","article-title":"Diet in pregnancy: A review of current challenges and recommendations","volume":"50","author":"Hart","year":"2025","journal-title":"Nutr. Bull."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1111\/obr.12288","article-title":"Risks associated with obesity in pregnancy, for the mother and baby: A systematic review of reviews","volume":"16","author":"Marchi","year":"2015","journal-title":"Obes. Rev."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Lewandowska, M., Wi\u0119ckowska, B., and Sajdak, S. (2020). Pre-pregnancy obesity, excessive gestational weight gain, and the risk of pregnancy-induced hypertension and gestational diabetes mellitus. J. Clin. Med., 9.","DOI":"10.3390\/jcm9061980"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1111\/jhn.12999","article-title":"Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: A narrative review","volume":"35","author":"Pearce","year":"2022","journal-title":"J. Hum. Nutr. Diet."},{"key":"ref_9","unstructured":"Rasmussen, K.M., and Yaktine, A.L. (2009). Weight Gain During Pregnancy: Reexamining the Guidelines, National Academies Press."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1080\/13557858.2017.1398312","article-title":"2009 IOM guidelines for gestational weight gain: How well do they predict outcomes across ethnic groups?","volume":"25","author":"Khanolkar","year":"2020","journal-title":"Ethn. Health"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"362.e1","DOI":"10.1016\/j.ajog.2015.01.027","article-title":"Weight gain in pregnancy: Does the Institute of Medicine have it right?","volume":"212","author":"Truong","year":"2015","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1017\/S0007114519003301","article-title":"A simple cut-off for waist-to-height ratio (0.5) can act as an indicator for cardiometabolic risk: Recent data from adults in the Health Survey for England","volume":"123","author":"Gibson","year":"2020","journal-title":"Br. J. Nutr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e13449","DOI":"10.1111\/obr.13449","article-title":"Association between maternal adiposity measures and adverse maternal outcomes of pregnancy: Systematic review and meta-analysis","volume":"23","author":"Heslehurst","year":"2022","journal-title":"Obes. Rev."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"103395","DOI":"10.1016\/j.eclinm.2025.103395","article-title":"The effect of maternal pre-pregnancy body mass index on hypertensive disorders of pregnancy (HDP): A systematic review and dose-response meta-analysis of cohort studies involving 50 million pregnancies","volume":"86","author":"Xiong","year":"2025","journal-title":"eClinicalMedicine"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.clnesp.2022.06.001","article-title":"Sedentary behavior, physical inactivity, abdominal obesity and obesity in adults and older adults: A systematic review and meta-analysis","volume":"50","author":"Silveira","year":"2022","journal-title":"Clin. Nutr. ESPEN"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e13615","DOI":"10.1111\/obr.13615","article-title":"Correlates of physical activity and sedentary behavior in adults living with overweight and obesity: A systematic review","volume":"24","author":"Curran","year":"2023","journal-title":"Obes. Rev."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1186\/s12966-017-0485-z","article-title":"Sedentary behaviours during pregnancy: A systematic review","volume":"14","author":"Fazzi","year":"2017","journal-title":"Int. J. Behav. Nutr. Phys. Act."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1007\/s43032-023-01321-w","article-title":"Effects of sedentary behavior on the complications experienced by pregnant women: A systematic review","volume":"31","author":"Osumi","year":"2024","journal-title":"Reprod. Sci."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"8531360","DOI":"10.1155\/2019\/8531360","article-title":"Prevalence of overweight and obesity among Libyan men and women","volume":"2019","author":"Lemamsha","year":"2019","journal-title":"BioMed Res. Int."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1753-4887.2011.00456.x","article-title":"Global nutrition transition and the pandemic of obesity in developing countries","volume":"70","author":"Popkin","year":"2012","journal-title":"Nutr. Rev."},{"key":"ref_21","first-page":"1","article-title":"Burden of non-communicable diseases risk factors in Libya and other Arabic countries: STEPwise survey comparative analysis","volume":"3","author":"Alsla","year":"2024","journal-title":"Int. J. Clin. Res. Rep."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Lemamsha, H., Randhawa, G., and Papadopoulos, C. (2022). Investigating the association between unhealthy dietary habits and obesity among Libyan adults. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19031076"},{"key":"ref_23","first-page":"666","article-title":"The effect of socioeconomic and cultural factors on the prevalence of obesity among women in Benghazi","volume":"11","author":"Adam","year":"2023","journal-title":"Glob. Sci. J."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Allen, L.N., Wild, C.E., Loffreda, G., Kak, M., Aghilla, M., Emahbes, T., Bonyani, A., Hatefi, A., Herbst, C., and El Saeh, H.M. (2022). Non-communicable disease policy implementation in Libya: A mixed methods assessment. PLoS Glob. Public Health, 2.","DOI":"10.1371\/journal.pgph.0000615"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Lemamsha, H., Papadopoulos, C., and Randhawa, G. (2018). Perceived environmental factors associated with obesity in Libyan men and women. Int. J. Environ. Res. Public Health, 15.","DOI":"10.3390\/ijerph15020301"},{"key":"ref_26","unstructured":"Lemamsha, H.A.A. (2016). Exploring the Risk and Protective Factors Associated with Obesity Amongst Libyan Adults (20\u201365 Years). [Ph.D. Thesis, University of Bedfordshire]. Available online: https:\/\/researchportal.beds.ac.uk\/en\/studentTheses\/exploring-the-risk-and-protective-factors-associated-with-obesity-3\/."},{"key":"ref_27","first-page":"51","article-title":"A sector in crisis: Seeking healthcare in Libya a decade after the revolution","volume":"128","author":"Bermejo","year":"2024","journal-title":"Conflu. Mediterr."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design, Harvard University Press.","DOI":"10.4159\/9780674028845"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e13601","DOI":"10.1111\/obr.13601","article-title":"Updating the association between socioeconomic status and obesity in low-income and lower-middle-income sub-Saharan African countries: A literature review","volume":"24","author":"Daran","year":"2023","journal-title":"Obes. Rev."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1067","DOI":"10.1111\/j.1467-789X.2012.01017.x","article-title":"Obesity and socioeconomic status in developing countries: A systematic review","volume":"13","author":"Dinsa","year":"2012","journal-title":"Obes. Rev."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Zhang, Y., Gao, X., Koch, P.A., Cai, X., Gao, M., Yue, J., Sun, Y., Sun, S., and Yu, H. (2025). Exploring the determinants of unhealthy dietary behaviors among pregnant women in China using the theory of planned behavior: A cross-sectional study. BMC Public Health, 25.","DOI":"10.1186\/s12889-025-24357-w"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1079\/PHN2003585","article-title":"Diet, nutrition and the prevention of excess weight gain and obesity","volume":"7","author":"Swinburn","year":"2004","journal-title":"Public Health Nutr."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Ke, J.F., Liu, S., Ge, R.L., Ma, L., and Li, M.F. (2023). Associations of maternal pre-pregnancy BMI and gestational weight gain with the risks of adverse pregnancy outcomes in Chinese women with gestational diabetes mellitus. BMC Pregnancy Childbirth, 23.","DOI":"10.1186\/s12884-023-05657-8"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Moradi, A., Norouzi, M., and Farkhani, E.M. (2026). Impact of gestational weight gain on adverse pregnancy outcomes in women with gestational diabetes: A retrospective cohort study. BMC Pediatr., 26.","DOI":"10.1186\/s12887-025-06371-4"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Li, N., Liu, E., Guo, J., Pan, L., Li, B., Wang, P., Liu, J., Wang, Y., Liu, G., and Baccarelli, A.A. (2013). Maternal prepregnancy body mass index and gestational weight gain on pregnancy outcomes. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0082310"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1055\/a-2597-8542","article-title":"Association of gestational weight gain with adverse pregnancy outcomes in individuals with obesity","volume":"43","author":"Onishi","year":"2026","journal-title":"Am. J. Perinatol."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Xiong, A., Huang, Y., Ke, J., Luo, S., Tong, Y., Zhao, L., Luo, B., and Liao, S. (2025). Second-trimester anthropometric estimators of cesarean section: The agreement between body roundness index, body mass index, body fat percentage, and waist circumference. BMC Pregnancy Childbirth, 25.","DOI":"10.1186\/s12884-025-07643-8"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Gao, X., Yan, Y., Xiang, S., Zeng, G., Liu, S., Sha, T., He, Q., Li, H., Tan, S., and Chen, C. (2017). The mutual effect of pre-pregnancy body mass index, waist circumference and gestational weight gain on obesity-related adverse pregnancy outcomes: A birth cohort study. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0177418"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"100166","DOI":"10.1016\/j.obpill.2025.100166","article-title":"Prevalence of obesity according to body mass index, waist circumference, and waist-to-height ratio in Peru: A systematic review and meta-analysis","volume":"13","author":"Ramos","year":"2025","journal-title":"Obes. Pillars"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1136\/jim-2018-000722","article-title":"Advanced body composition assessment: From body mass index to body composition profiling","volume":"66","author":"Borga","year":"2018","journal-title":"J. Investig. Med."},{"key":"ref_41","first-page":"379","article-title":"Bioelectrical impedance analysis instruments: How do they differ, what do we need for clinical assessment?","volume":"28","author":"Dupertuis","year":"2025","journal-title":"Curr. Opin. Clin. Nutr. Metab. Care"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1123\/ijsnem.2018-0283","article-title":"Reliability and validity of commercially available low-cost bioelectrical impedance analysis","volume":"29","author":"Vasold","year":"2019","journal-title":"Int. J. Sport Nutr. Exerc. Metab."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Nakanishi, K., Saijo, Y., Ishikawa, Y., Yoshizawa, A., Kanai, A., Yokohama, Y., and Kato, Y. (2025). Association between postpartum depression and maternal skeletal muscle mass evaluated using bioelectrical impedance analysis: A prospective cohort study. BMC Pregnancy Childbirth, 26.","DOI":"10.1186\/s12884-025-08515-x"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"11","DOI":"10.5455\/msm.2025.37.11-17","article-title":"Anthropometric data by using bioelectrical analysis as a parameter for new classification and definition of obesity","volume":"37","author":"Salihefendic","year":"2025","journal-title":"Mater. Socio-Medica"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1111\/aogs.13331","article-title":"Cross-sectional studies\u2014What are they good for?","volume":"97","author":"Kesmodel","year":"2018","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Baumeister, S.E., Kocher, T., Papapanou, P.N., Holtfreter, B., and Demmer, R.T. (2026). Cross-sectional studies: Strengths, limitations, and methodological considerations. J. Periodontal Res., Online ahead of print.","DOI":"10.1111\/jre.70063"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"S65","DOI":"10.1016\/j.chest.2020.03.012","article-title":"Cross-sectional studies: Strengths, weaknesses, and recommendations","volume":"158","author":"Wang","year":"2020","journal-title":"Chest"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1017\/S0007114524001855","article-title":"The impact of cohort inclusion\/exclusion criteria on pregnancy weight gain chart percentiles","volume":"132","author":"Carrilho","year":"2024","journal-title":"Br. J. Nutr."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Fakhraei, R., Denize, K., Simon, A., Sharif, A., Zhu-Pawlowsky, J., Dingwall-Harvey, A.L., Hutton, B., Pratt, M., Skidmore, B., and Ahmadzai, N. (2022). Predictors of adverse pregnancy outcomes in pregnant women living with obesity: A systematic review. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19042063"},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Han, Y., Wang, J., Wang, X., Ouyang, L., and Li, Y. (2022). Relationship between subclinical hypothyroidism in pregnancy and hypertensive disorder of pregnancy: A systematic review and meta-analysis. Front. Endocrinol., 13.","DOI":"10.3389\/fendo.2022.823710"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"2032413","DOI":"10.1155\/2018\/2032413","article-title":"Reference intervals of thyroid hormones and correlation of BMI with thyroid function in healthy Zhuang ethnic pregnant women","volume":"2018","author":"Sheng","year":"2018","journal-title":"BioMed Res. Int."},{"key":"ref_52","first-page":"762","article-title":"Sampling methods in research: A review","volume":"7","author":"Makwana","year":"2023","journal-title":"Int. J. Trend Sci. Res. Dev."},{"key":"ref_53","first-page":"237","article-title":"Determining sample size; how to calculate survey sample size","volume":"2","author":"Taherdoost","year":"2017","journal-title":"Int. J. Econ. Manag. Syst."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"100662","DOI":"10.1016\/j.oor.2024.100662","article-title":"How to choose a sampling technique and determine sample size for research: A simplified guide for researchers","volume":"12","author":"Ahmed","year":"2024","journal-title":"Oral Oncol. Rep."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1177\/0193841X13516324","article-title":"Stratified sampling using cluster analysis: A sample selection strategy for improved generalizations from experiments","volume":"37","author":"Tipton","year":"2013","journal-title":"Eval. Rev."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"050012","DOI":"10.1063\/5.0092740","article-title":"Stratified sampling using cluster analysis","volume":"2472","author":"Haron","year":"2022","journal-title":"AIP Conf. Proc."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"202196","DOI":"10.1016\/j.jeph.2024.202196","article-title":"How should a cluster randomized trial be analyzed?","volume":"72","author":"Billot","year":"2024","journal-title":"J. Epidemiol. Popul. Health"},{"key":"ref_58","first-page":"100168","article-title":"Sample size requirements and intra-cluster correlations for stepped wedge cluster randomised trials in intensive care medicine: A practical guide","volume":"28","author":"Baggio","year":"2026","journal-title":"Crit. Care Resusc."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Parker, K., Nunns, M., Xiao, Z., Ford, T., Stallard, P., Kuyken, W., Axford, N., and Ukoumunne, O.C. (2025). Patterns of intra-cluster correlation coefficients in school-based cluster randomised controlled trials of interventions for improving social-emotional functioning outcomes in pupils: A secondary data analysis of five UK-based studies. BMC Med. Res. Methodol., 25.","DOI":"10.1186\/s12874-025-02574-6"},{"key":"ref_60","first-page":"447","article-title":"Micronutrient supplementation and socioeconomic determinants among pregnant women in Tobruk, Libya: A cross-sectional analysis","volume":"6","author":"Lemamsha","year":"2025","journal-title":"Sharwes Sci. J."},{"key":"ref_61","unstructured":"World Health Organization (2013). WHO STEPS Instrument for Noncommunicable Disease Risk Factor Surveillance [Internet], World Health Organization."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"1192","DOI":"10.1038\/sj.ijo.0801049","article-title":"Physical inactivity, sedentary lifestyle and obesity in the European Union","volume":"23","author":"Hu","year":"1999","journal-title":"Int. J. Obes."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"2317","DOI":"10.1007\/s40279-018-0961-x","article-title":"Physical activity questionnaires for pregnancy: A systematic review of measurement properties","volume":"48","author":"Sattler","year":"2018","journal-title":"Sports Med."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Koo, M., and Yang, S.W. (2025). Likert-type scale. Encyclopedia, 5.","DOI":"10.3390\/encyclopedia5010018"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1097\/PHM.0000000000002028","article-title":"Why questionnaire scores are not measures: A question-raising article","volume":"102","author":"Tesio","year":"2023","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"539","DOI":"10.3122\/jabfm.2008.06.070265","article-title":"Creating a clinical screening questionnaire for eating behaviors associated with overweight and obesity","volume":"21","author":"Greenwood","year":"2008","journal-title":"J. Am. Board Fam. Med."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1016\/S0191-8869(98)00086-5","article-title":"How to score questionnaires","volume":"25","author":"Hofstee","year":"1998","journal-title":"Personal. Individ. Differ."},{"key":"ref_68","doi-asserted-by":"crossref","unstructured":"Brusco, N.K., and Watts, J.J. (2015). Empirical evidence of recall bias for primary health care visits. BMC Health Serv. Res., 15.","DOI":"10.1186\/s12913-015-1039-1"},{"key":"ref_69","first-page":"28","article-title":"How to identify information bias due to self-reporting in epidemiological research","volume":"7","author":"Fadnes","year":"2009","journal-title":"Internet J. Epidemiol."},{"key":"ref_70","doi-asserted-by":"crossref","unstructured":"Cannon, T., and Choi, J. (2019). Development of a segmental bioelectrical impedance spectroscopy device for body composition measurement. Sensors, 19.","DOI":"10.3390\/s19224825"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"e13844","DOI":"10.1111\/obr.13844","article-title":"Development and clinical application of bioelectrical impedance analysis method for body composition assessment","volume":"26","author":"Son","year":"2025","journal-title":"Obes. Rev."},{"key":"ref_72","doi-asserted-by":"crossref","unstructured":"Oliver, C.J., Del Vecchio, L., Minehan, M., Climstein, M., Rosic, N., Myers, S., and Tinsley, G. (2026). The validity of bioelectrical impedance analysis compared to a four-compartment model in healthy adults: A systematic review. J. Funct. Morphol. Kinesiol., 11.","DOI":"10.3390\/jfmk11010065"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1038\/s41598-024-51274-6","article-title":"Combined maternal central adiposity measures in relation to infant birth size","volume":"14","author":"Lindberger","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_74","doi-asserted-by":"crossref","unstructured":"Aji, A.S., Lipoeto, N.I., Yusrawati, Y., Malik, S.G., Kusmayanti, N.A., Susanto, I., Majidah, N.M., Nurunniyah, S., Alfiana, R.D., and Wahyuningsih, W. (2022). Association between pre-pregnancy body mass index and gestational weight gain on pregnancy outcomes: A cohort study in Indonesian pregnant women. BMC Pregnancy Childbirth, 22.","DOI":"10.1186\/s12884-022-04815-8"},{"key":"ref_75","first-page":"e28695","article-title":"Increasing Pre-pregnancy Body Mass Index and Pregnancy Outcomes in the United States","volume":"14","author":"Akinyemi","year":"2022","journal-title":"Cureus"},{"key":"ref_76","doi-asserted-by":"crossref","unstructured":"Rahnemaei, F.A., Abdi, F., Pakzad, R., Sharami, S.H., Mokhtari, F., and Kazemian, E. (2022). Association of body composition in early pregnancy with gestational diabetes mellitus: A meta-analysis. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0271068"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1002\/ijgo.12202","article-title":"Correlation between pre-pregnancy body mass index and maternal visceral adiposity with fetal biometry during the second trimester","volume":"138","author":"Lopes","year":"2017","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_78","doi-asserted-by":"crossref","unstructured":"Sheikh, M.A., Abelsen, B., and Olsen, J.A. (2016). Differential recall bias, intermediate confounding, and mediation analysis in life course epidemiology: An analytic framework with empirical example. Front. Psychol., 7.","DOI":"10.3389\/fpsyg.2016.01828"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1177\/1753495X13495192","article-title":"The importance of visceral fat mass in obese pregnant women and relation with pregnancy outcomes","volume":"7","author":"Balani","year":"2014","journal-title":"Obstet. Med."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"2511","DOI":"10.1111\/aogs.14968","article-title":"Prepregnancy body mass index and visceral fat exhibit divergent associations with metabolic factors in pregnant women with obesity: A Norwegian cohort study","volume":"103","author":"Bonnichsen","year":"2024","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"e086703","DOI":"10.1136\/bmjopen-2024-086703","article-title":"Combination of body mass index and body fat percentage in middle and late pregnancy to predict pregnancy outcomes in patients with gestational diabetes in Wenzhou, China: A single-centre retrospective cohort study","volume":"14","author":"Chen","year":"2024","journal-title":"BMJ Open"},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"1023","DOI":"10.1111\/jog.14633","article-title":"Modifiable predictors to maternal visceral adipose tissue during pregnancy: A clinical, demographic, and nutritional study","volume":"47","author":"Bernardi","year":"2021","journal-title":"J. Obstet. Gynaecol. Res."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1111\/j.1744-6570.1975.tb01393.x","article-title":"A quantitative approach to content validity","volume":"28","author":"Lawshe","year":"1975","journal-title":"Pers. Psychol."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1177\/19458924231207137","article-title":"Assessing the psychometric validity of the epistaxis severity score: Internal consistency and test\u2013retest reliability","volume":"38","author":"Gong","year":"2024","journal-title":"Am. J. Rhinol. Allergy"},{"key":"ref_85","doi-asserted-by":"crossref","unstructured":"Hunot-Alexander, C., Beeken, R.J., Goodman, W., Fildes, A., Croker, H., Llewellyn, C., and Steinsbekk, S. (2019). Confirmation of the factor structure and reliability of the \u2018Adult Eating Behavior Questionnaire\u2019 in an adolescent sample. Front. Psychol., 10.","DOI":"10.3389\/fpsyg.2019.01991"},{"key":"ref_86","doi-asserted-by":"crossref","unstructured":"Vaz, S., Falkmer, T., Passmore, A.E., Parsons, R., and Andreou, P. (2013). The case for using the repeatability coefficient when calculating test\u2013retest reliability. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0073990"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"123","DOI":"10.3758\/s13428-025-02599-1","article-title":"Sample size matters when estimating test\u2013retest reliability of behaviour","volume":"57","author":"Williams","year":"2025","journal-title":"Behav. Res. Methods"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"e12715","DOI":"10.1111\/ijn.12715","article-title":"The forward\u2013backward and dual-panel translation methods are comparable in producing semantic equivalent versions of a heart quality of life questionnaire","volume":"25","author":"Lee","year":"2019","journal-title":"Int. J. Nurs. Pract."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1080\/14737167.2020.1734453","article-title":"Translation and back-translation methodology in health research: A critique","volume":"20","author":"Ozolins","year":"2020","journal-title":"Expert Rev. Pharmacoecon. Outcomes Res."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"402","DOI":"10.4097\/kjae.2013.64.5.402","article-title":"The prevention and handling of the missing data","volume":"64","author":"Kang","year":"2013","journal-title":"Korean J. Anesthesiol."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"2308","DOI":"10.1016\/j.sapharm.2021.03.009","article-title":"Missing data in surveys: Key concepts, approaches, and applications","volume":"18","author":"Mirzaei","year":"2022","journal-title":"Res. Soc. Adm. Pharm."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"106974","DOI":"10.1016\/j.ntt.2021.106974","article-title":"Recruitment and retention of pregnant women in prospective birth cohort studies: A scoping review and content analysis of the literature","volume":"85","author":"Goldstein","year":"2021","journal-title":"Neurotoxicol. Teratol."},{"key":"ref_93","first-page":"MR000036","article-title":"Strategies designed to help healthcare professionals to recruit participants to research studies","volume":"2","author":"Preston","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1017\/S1368980016002986","article-title":"Missing data in FFQs: Making assumptions about item non-response","volume":"20","author":"Lamb","year":"2017","journal-title":"Public Health Nutr."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"2050312118822912","DOI":"10.1177\/2050312118822912","article-title":"How handling missing data may impact conclusions: A comparison of six different imputation methods for categorical questionnaire data","volume":"7","author":"Stavseth","year":"2019","journal-title":"SAGE Open Med."},{"key":"ref_96","unstructured":"Field, A.P. (2024). Discovering Statistics Using IBM SPSS Statistics, Sage. [6th ed.]."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/j.ejogrb.2025.01.008","article-title":"Comparison of body composition change, measured with bioelectrical impedance analysis, between singleton and twin pregnancy: A prospective cohort study","volume":"306","author":"Choi","year":"2025","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1016\/j.clnesp.2022.03.021","article-title":"Exploring comparative assessment of adiposity measures during pregnancy and postpartum","volume":"49","author":"Maran","year":"2022","journal-title":"Clin. Nutr. ESPEN"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"658056","DOI":"10.1155\/2014\/658056","article-title":"An investigation of the significance of residual confounding effect","volume":"2014","author":"Liang","year":"2014","journal-title":"BioMed Res. Int."},{"key":"ref_100","first-page":"97","article-title":"Tutorial on methods to adjust for confounding variable in medical research","volume":"14","author":"Dina","year":"2025","journal-title":"J. Community Health Res."},{"key":"ref_101","doi-asserted-by":"crossref","unstructured":"Geberu, D.M., Abera, K.M., Tsega, Y., Endawkie, A., Negash, W.D., Workie, A.M., Yohannes, L., Getnet, M., Worku, N., and Belay, A.Y. (2025). Pooled prevalence and factors of overweight\/obesity among women of reproductive age in low and middle-income countries with high maternal mortality: A multi-level analysis of recent demographic and health surveys. PLoS ONE, 20.","DOI":"10.1371\/journal.pone.0316962"},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"26","DOI":"10.18203\/2320-1770.ijrcog20205750","article-title":"Maternal and perinatal outcomes in pregnancy with high BMI in the Jabal Akhdar region of Libya","volume":"10","author":"Elghazal","year":"2021","journal-title":"Int. J. Reprod. Contracept. Obstet. Gynecol."},{"key":"ref_103","first-page":"353","article-title":"A comparative study of the effect of BMI on labour outcomes, delivery process, and postpartum women\u2019s health, at governmental hospitals in two Libyan cities","volume":"26","author":"Alwan","year":"2021","journal-title":"Int. J. Prog. Sci. Technol."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1007\/s13668-024-00597-x","article-title":"Anthropometric measurements and laboratory methods for pregnancy: An update review to evaluation of body composition","volume":"14","year":"2025","journal-title":"Curr. Nutr. Rep."},{"key":"ref_105","first-page":"15","article-title":"The effect of maternal obesity on pregnancy outcomes among Libyan women with singleton pregnancy","volume":"16","author":"Arebi","year":"2019","journal-title":"Alostath"},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.3390\/nursrep14020094","article-title":"Obesity prevalence and its impact on maternal and neonatal outcomes among pregnant women: A retrospective cross-sectional study design","volume":"14","author":"AlAnnaz","year":"2024","journal-title":"Nurs. Rep."},{"key":"ref_107","doi-asserted-by":"crossref","unstructured":"Costa, J.C., Wang, D., Wang, M., Liu, E., Partap, U., Cliffer, I., and Fawzi, W.W. (2024). Gestational weight gain at the national, regional, and income group levels based on 234 national household surveys from 70 low-income and middle-income countries. PLoS Glob. Public Health, 4.","DOI":"10.1371\/journal.pgph.0003484"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"923","DOI":"10.1055\/s-0035-1557868","article-title":"Prevalence and associated risk factors for obesity during pregnancy over time","volume":"75","author":"Zollner","year":"2015","journal-title":"Geburtshilfe Frauenheilkd."},{"key":"ref_109","doi-asserted-by":"crossref","unstructured":"Flores-Quijano, M.E., S\u00e1mano, R., Barrientos-Galeana, E., and Borboa-Olivares, H. (2026). Body water during pregnancy: Physiology, clinical significance and assessment methods: A narrative review. Nutrients, 18.","DOI":"10.3390\/nu18071031"},{"key":"ref_110","doi-asserted-by":"crossref","unstructured":"Wahabi, H., Fayed, A., Esmaeil, S., and Almadhun, A.A. (2025). Maternal nutrition and gestational weight gain among Saudi women: Riyadh Mother and Baby Follow Up Study (RAHMA Explore). Healthcare, 13.","DOI":"10.3390\/healthcare13121446"},{"key":"ref_111","first-page":"15","article-title":"Associations between maternal overweight and obesity with cesarean section delivery in Middle East and North Africa region: A systematic review, meta-analysis, and attributable risk","volume":"15","author":"Alam","year":"2026","journal-title":"Syst. Rev."},{"key":"ref_112","doi-asserted-by":"crossref","unstructured":"Ng, S.K., Cameron, C.M., Hills, A.P., McClure, R.J., and Scuffham, P.A. (2014). Socioeconomic disparities in prepregnancy BMI and impact on maternal and neonatal outcomes and postpartum weight retention: The EFHL longitudinal birth cohort study. BMC Pregnancy Childbirth, 14.","DOI":"10.1186\/1471-2393-14-314"},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"e038187","DOI":"10.1136\/bmjopen-2020-038187","article-title":"Gestational weight gain and adverse pregnancy outcomes: A prospective cohort study","volume":"10","author":"Wu","year":"2020","journal-title":"BMJ Open"},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"bvae176","DOI":"10.1210\/jendso\/bvae176","article-title":"Socioeconomic status and obesity","volume":"8","author":"Autret","year":"2024","journal-title":"J. Endocr. Soc."},{"key":"ref_115","first-page":"1","article-title":"Obesity, socioeconomic transitions, and the evolving social gradient of non-communicable diseases in low- and middle-income countries","volume":"8","author":"Barik","year":"2025","journal-title":"Arch. Women Health Care"},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"11129","DOI":"10.1038\/s41598-025-90079-z","article-title":"Maternal obesity, lifestyle factors and associated pregnancy outcomes in Ibadan, Nigeria: A Nigerian cohort study","volume":"15","author":"Adeoye","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"1506","DOI":"10.1007\/s10995-016-1949-5","article-title":"Fast food intake in relation to employment status, stress, depression, and dietary behaviors in low-income overweight and obese pregnant women","volume":"20","author":"Chang","year":"2016","journal-title":"Matern. Child Health J."},{"key":"ref_118","doi-asserted-by":"crossref","unstructured":"Wittels, P., Kay, T., and Mansfield, L. (2022). Adopting and maintaining a healthy lifestyle in low SES families: How the experience of motherhood shapes responses to dietary and physical activity public health guidance. BMC Public Health, 22.","DOI":"10.1186\/s12889-022-13502-4"},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"e71654","DOI":"10.1002\/hsr2.71654","article-title":"Awareness of obesity and diabetes in Libya: Insights from a cross-sectional study","volume":"9","author":"Mohamed","year":"2025","journal-title":"Health Sci. Rep."},{"key":"ref_120","doi-asserted-by":"crossref","unstructured":"Mehrabi, F., Ahmaripour, N., Jalali-Farahani, S., and Amiri, P. (2021). Barriers to weight management in pregnant mothers with obesity: A qualitative study on mothers with low socioeconomic background. BMC Pregnancy Childbirth, 21.","DOI":"10.1186\/s12884-021-04243-0"},{"key":"ref_121","doi-asserted-by":"crossref","unstructured":"Pico, M.L., Grunnet, L.G., Vinter, C.A., Aagaard-Hansen, J., and Nielsen, K.K. (2023). Barriers and facilitators for sustainable weight loss in the pre-conception period among Danish women with overweight or obesity: A qualitative study. BMC Public Health, 23.","DOI":"10.1186\/s12889-023-16676-7"},{"key":"ref_122","doi-asserted-by":"crossref","unstructured":"Charnley, M., Newson, L., Weeks, A., and Abayomi, J. (2024). A qualitative exploration of the experiences of pregnant women living with obesity and accessing antenatal care. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0302599"},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1093\/pubmed\/fdx038","article-title":"The influence of socioeconomic status on gestational weight gain: A systematic review","volume":"40","author":"Alberdi","year":"2018","journal-title":"J. Public Health"},{"key":"ref_124","first-page":"1","article-title":"Socio-economic factors of differences in public health-related variables among women: A cross-sectional study","volume":"1","author":"Sheikh","year":"2022","journal-title":"J. Econ. Sci."},{"key":"ref_125","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1097\/JPN.0000000000000400","article-title":"Obesity and socioeconomic disparities: Rethinking causes and perinatal care","volume":"33","author":"Jevitt","year":"2019","journal-title":"J. Perinat. Neonatal Nurs."},{"key":"ref_126","doi-asserted-by":"crossref","unstructured":"Elmahgoub, S., Mohamed, H., El Taguri, A., Beregi, T., Aburub, A., and \u00c1cs, P. (2025). Motives and barriers to physical activity participation among university students. Int. J. Environ. Res. Public Health, 22.","DOI":"10.3390\/ijerph22111646"},{"key":"ref_127","doi-asserted-by":"crossref","unstructured":"Alnaqbi, S.E., Sohail, R., Radwan, H.M., Mohamad, M.N., Zeb, F., Hasan, H., Hashim, M., Osaili, T., AlBlooshi, S., and Al Dhaheri, A.S. (2025). Physical activity, screen time, dietary habits, and health outcomes among children and adolescents in the Middle East and North Africa region: A narrative review. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1628904"},{"key":"ref_128","doi-asserted-by":"crossref","first-page":"98","DOI":"10.21101\/cejph.a4011","article-title":"Physical activity and gender differences: Correlates of compliance with recommended levels of five forms of physical activity among students at nine universities in Libya","volume":"22","author":"Khalil","year":"2014","journal-title":"Cent. Eur. J. Public Health"},{"key":"ref_129","doi-asserted-by":"crossref","unstructured":"Gonzalez Ramirez, G., and Bola\u00f1os Mu\u00f1oz, L. (2023). Relationship of sedentary lifestyle with obesity and comorbidities. Physical Activity and Bariatric Surgery, Springer International Publishing.","DOI":"10.1007\/978-3-031-26614-0_1"},{"key":"ref_130","doi-asserted-by":"crossref","first-page":"130","DOI":"10.3390\/women4020010","article-title":"Effects of physical activity on quality of life of pregnant women with overweight or obesity: A systematic review","volume":"4","author":"Bernardo","year":"2024","journal-title":"Women"},{"key":"ref_131","doi-asserted-by":"crossref","unstructured":"Garg, D., Smith, E., and Attuquayefio, T. (2025). Watching television while eating increases food intake: A systematic review and meta-analysis of experimental studies. Nutrients, 17.","DOI":"10.3390\/nu17010166"},{"key":"ref_132","doi-asserted-by":"crossref","unstructured":"Xu, X., Liu, D., Rao, Y., Zeng, H., Zhang, F., Wang, L., Xie, Y., Sharma, M., and Zhao, Y. (2018). Prolonged screen viewing times and sociodemographic factors among pregnant women: A cross-sectional survey in China. Int. J. Environ. Res. Public Health, 15.","DOI":"10.3390\/ijerph15030403"},{"key":"ref_133","first-page":"394","article-title":"Prevalence and multilevel risk factors for overweight and obesity among children aged 6\u201313 years in public and private schools in Derna, Libya: A school-based cross-sectional study","volume":"7","author":"Lemamsha","year":"2026","journal-title":"Sharwes Sci. J."},{"key":"ref_134","first-page":"26","article-title":"Impact of diet and lifestyle modification on obesity and thyroid symptom severity in adults with hypothyroidism in Tobruk: A six-month pre\u2013post study","volume":"6","author":"Lemamsha","year":"2026","journal-title":"Derna Acad. J. Appl. Sci."},{"key":"ref_135","doi-asserted-by":"crossref","unstructured":"Mart\u00edn-Estal, I., and Castorena-Torres, F. (2022). Gestational diabetes mellitus and energy-dense diet: What is the role of the insulin\/IGF axis?. Front. Endocrinol., 13.","DOI":"10.3389\/fendo.2022.916042"},{"key":"ref_136","doi-asserted-by":"crossref","unstructured":"Triunfo, S. (2026). Nutrition in pregnancy and early life: A critical window of vulnerability but also of opportunity. Nutrients, 18.","DOI":"10.3390\/nu18050793"},{"key":"ref_137","doi-asserted-by":"crossref","first-page":"52","DOI":"10.11606\/S1518-8787.2019053000909","article-title":"Dietary patterns of pregnant women, maternal excessive body weight and gestational diabetes","volume":"53","author":"Zuccolotto","year":"2019","journal-title":"Rev. Saude Publica"},{"key":"ref_138","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1080\/17437199.2021.1938632","article-title":"Factors influencing health behaviour change during pregnancy: A systematic review and meta-synthesis","volume":"15","author":"Rockliffe","year":"2021","journal-title":"Health Psychol. Rev."},{"key":"ref_139","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.appet.2017.02.004","article-title":"Understanding maternal dietary choices during pregnancy: The role of social norms and mindful eating","volume":"112","author":"Hutchinson","year":"2017","journal-title":"Appetite"},{"key":"ref_140","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1017\/S1368980016002937","article-title":"Determinants of dietary patterns and diet quality during pregnancy: A systematic review with narrative synthesis","volume":"20","author":"Doyle","year":"2017","journal-title":"Public Health Nutr."},{"key":"ref_141","doi-asserted-by":"crossref","unstructured":"Monda, A., De Stefano, M.I., Villano, I., Allocca, S., Casillo, M., Messina, A., Monda, V., Moscatelli, F., Dipace, A., and Limone, P. (2024). Ultra-processed food intake and increased risk of obesity: A narrative review. Foods, 13.","DOI":"10.3390\/foods13162627"},{"key":"ref_142","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1038\/s41574-025-01143-7","article-title":"The role of ultra-processed food in obesity","volume":"21","author":"Juul","year":"2025","journal-title":"Nat. Rev. Endocrinol."},{"key":"ref_143","doi-asserted-by":"crossref","unstructured":"Dicken, S.J., and Batterham, R.L. (2021). The role of diet quality in mediating the association between ultra-processed food intake, obesity and health-related outcomes: A review of prospective cohort studies. Nutrients, 14.","DOI":"10.3390\/nu14010023"},{"key":"ref_144","doi-asserted-by":"crossref","first-page":"1351","DOI":"10.3945\/ajcn.116.151332","article-title":"Impact of breakfast skipping compared with dinner skipping on regulation of energy balance and metabolic risk","volume":"105","author":"Nas","year":"2017","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_145","doi-asserted-by":"crossref","unstructured":"Yang, B., Lian, L., Xing, K., Cen, Y., Zhao, Y., and Zhang, Y. (2025). Association of skipping breakfast with metabolic syndrome and its components: A systematic review and meta-analysis of observational studies. Nutrients, 17.","DOI":"10.3390\/nu17193155"},{"key":"ref_146","doi-asserted-by":"crossref","unstructured":"Atomei, O.L., Vicoveanu, P., Ia\u021bcu, C.O., Gliga, F.I., Craciun, C.C., and Tarcea, M. (2025). Associations between maternal meal frequency patterns during pregnancy and neonatal anthropometric outcomes: A quantitative cross-sectional study. Nutrients, 17.","DOI":"10.3390\/nu17152437"},{"key":"ref_147","doi-asserted-by":"crossref","unstructured":"Buijlayyil, M., Kiraz, A., and Lemamsha, H. (2025). Sustainability education for post-disaster recovery: A qualitative study of community and policy perspectives in Derna, Libya. Sustainability, 17.","DOI":"10.3390\/su172210181"},{"key":"ref_148","doi-asserted-by":"crossref","unstructured":"Chaabane, S., Chaabna, K., Doraiswamy, S., Mamtani, R., and Cheema, S. (2021). Barriers and facilitators associated with physical activity in the Middle East and North Africa region: A systematic overview. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18041647"},{"key":"ref_149","doi-asserted-by":"crossref","first-page":"5543684","DOI":"10.1155\/2022\/5543684","article-title":"Facilitators, barriers, and structural determinants of physical activity in nulliparous pregnant women: A qualitative study","volume":"2022","author":"Kianfard","year":"2022","journal-title":"J. Pregnancy"},{"key":"ref_150","first-page":"279","article-title":"Effectiveness of a dietary management intervention on modifiable cardiovascular risk factors among adults with chronic heart disease in Tobruk, Libya: A three-month prospective study","volume":"7","author":"Lemamsha","year":"2026","journal-title":"Sharwes Sci. J."},{"key":"ref_151","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1093\/aje\/kwac037","article-title":"Can cross-sectional studies contribute to causal inference? It depends","volume":"192","author":"Savitz","year":"2023","journal-title":"Am. J. Epidemiol."},{"key":"ref_152","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1097\/PRS.0b013e3181de24bc","article-title":"Identifying and avoiding bias in research","volume":"126","author":"Pannucci","year":"2010","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_153","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1136\/ebnurs-2024-104231","article-title":"Understanding sources of bias in research","volume":"28","author":"Smith","year":"2025","journal-title":"Evid. Based Nurs."},{"key":"ref_154","doi-asserted-by":"crossref","first-page":"S400","DOI":"10.1093\/cid\/ciu726","article-title":"Recruitment and retention of pregnant women into clinical research trials: An overview of challenges, facilitators, and best practices","volume":"59","author":"Frew","year":"2014","journal-title":"Clin. Infect. Dis."},{"key":"ref_155","doi-asserted-by":"crossref","first-page":"442","DOI":"10.3109\/01443615.2013.767787","article-title":"Recruitment of pregnant women in research","volume":"33","author":"Thakar","year":"2013","journal-title":"J. Obstet. Gynaecol."},{"key":"ref_156","doi-asserted-by":"crossref","first-page":"e2120377119","DOI":"10.1073\/pnas.2120377119","article-title":"Examining the generalizability of research findings from archival data","volume":"119","author":"Delios","year":"2022","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_157","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1556\/ComEc.8.2007.1.14","article-title":"Multi-stage cluster sampling for estimating average species richness at different spatial grains","volume":"8","author":"Baffetta","year":"2007","journal-title":"Community Ecol."},{"key":"ref_158","first-page":"253","article-title":"The advantage and disadvantage of implicitly stratified sampling","volume":"13","author":"Lynn","year":"2019","journal-title":"Methods Data Anal."},{"key":"ref_159","first-page":"25152459261416497","article-title":"Handling item-level missing data in linear regression: A tutorial","volume":"9","author":"Zhang","year":"2026","journal-title":"Adv. Methods Pract. Psychol. Sci."},{"key":"ref_160","doi-asserted-by":"crossref","first-page":"915","DOI":"10.1079\/PHN2002383","article-title":"Bias in dietary-report instruments and its implications for nutritional epidemiology","volume":"5","author":"Kipnis","year":"2002","journal-title":"Public Health Nutr."},{"key":"ref_161","doi-asserted-by":"crossref","first-page":"106868","DOI":"10.1016\/j.envint.2021.106868","article-title":"An approach to quantifying the potential importance of residual confounding in systematic reviews of observational studies: A GRADE concept paper","volume":"157","author":"Verbeek","year":"2021","journal-title":"Environ. Int."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/17\/2828\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T18:37:37Z","timestamp":1787942257000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/17\/2828"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,28]]},"references-count":161,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["nu18172828"],"URL":"https:\/\/doi.org\/10.3390\/nu18172828","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,28]]}}}