Barriers and facilitators to shared decision-making among African-Americans with diabetes

INTRODUCTION

Shared decision-making (SDM) between patients and their physicians is associated with improved diabetes health outcomes. African-Americans have less SDM than Whites, which may contribute to diabetes racial disparities. To date, there has been little research on SDM among African-Americans.

OBJECTIVE

We explored the barriers and facilitators to SDM among African-Americans with diabetes.

METHODS

Qualitative research design with a phenomenological methodology using in-depth interviews (n = 24) and five focus groups (n = 27). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted using an iterative process.

PARTICIPANTS

We utilized a purposeful sample of African-American adult patients with diabetes. All patients had insurance and received their care at an academic medical center.

RESULTS

Patients identified multiple SDM barriers/facilitators, including the patient/provider power imbalance that was perceived to be exacerbated by race. Patient-related factors included health literacy, fear/denial, family experiences and self-efficacy. Reported physician-related barriers/facilitators include patient education, validating patient experiences, medical knowledge, accessibility and availability, and interpersonal skills.

DISCUSSION

Barriers/facilitators of SDM exist among African-Americans with diabetes, which can be effectively addressed in the outpatient setting. Primary care physicians, particularly academic internists, may be uniquely situated to address these barriers/facilitators and train future physicians to do so as well.

Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system

BACKGROUND

African-American women have the highest breast cancer death rates of all racial/ethnic groups in the US. Reasons for these disparities are multi-factorial, but include lower mammogram utilization among this population. Cultural attitudes and beliefs, such as fear and fatalism, have not been fully explored as potential barriers to mammography among African-American women.

OBJECTIVE

To explore the reasons for fear associated with breast cancer screening among low-income African-American women.

METHODS

We conducted four focus groups (n = 29) among a sample of African-American women at an urban academic medical center. We used trained race-concordant interviewers with experience discussing preventive health behaviors. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted using an iterative process, and each transcription was independently coded by members of the research team.

MAIN RESULTS

Several major themes arose in our exploration of fear and other psychosocial barriers to mammogram utilization, including negative health care experiences, fear of the health care system, denial and repression, psychosocial issues, delays in seeking health care, poor health outcomes and fatalism. We constructed a conceptual model for understanding these themes.

CONCLUSIONS

Fear of breast cancer screening among low-income African-American women is multi-faceted, and reflects shared experiences within the health care system as well as the psychosocial context in which women live. This study identifies a prominent role for clinicians, particularly primary care physicians, and the health care system to address these barriers to mammogram utilization within this population.

How is shared decision-making defined among African-Americans with diabetes?

OBJECTIVE

This study investigates how shared decision-making (SDM) is defined by African-American patients with diabetes, and compares patients' conceptualization of SDM with the Charles model.

METHODS

We utilized race-concordant interviewers/moderators to conduct in-depth interviews and focus groups among a purposeful sample of African-American patients with diabetes. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was done using an iterative process and each transcription was independently coded by two members of the research team.

RESULTS

Although the conceptual domains were similar, patient definitions of what it means to "share" in the decision-making process differed significantly from the Charles model of SDM. Patients stressed the value of being able to "tell their story and be heard" by physicians, emphasized the importance of information sharing rather than decision-making sharing, and included an acceptable role for non-adherence as a mechanism to express control and act on treatment preferences.

CONCLUSION

Current instruments may not accurately measure decision-making preferences of African-American patients with diabetes.

PRACTICE IMPLICATIONS

Future research should develop instruments to effectively measure decision-making preferences within this population. Emphasizing information-sharing that validates patients' experiences may be particularly meaningful to African-Americans with diabetes.

Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women

The authors conduct a systematic review of the literature to identify interventions designed to enhance breast cancer screening, diagnosis, and treatment among minority women. Most trials in this area have focused on breast cancer screening, while relatively few have addressed diagnostic testing or breast cancer treatment. Among patient-targeted screening interventions, those that are culturally tailored or addressed financial or logistical barriers are generally more effective than reminder-based interventions, especially among women with fewer financial resources and those without previous mammography. Chart-based reminders increase physician adherence to mammography guidelines but are less effective at increasing clinical breast examination. Several trials demonstrate that case management is an effective strategy for expediting diagnostic testing after screening abnormalities have been found. Additional support for these and other proven health care organization-based interventions appears justified and may be necessary to eliminate racial and ethnic breast cancer disparities.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

An innovative partnership to address breast cancer screening among vulnerable populations

CONTEXT

Breast cancer is the most common non-skin malignancy among U.S. women. Vulnerable populations such as low-income women, racial/ethnic minorities, and the uninsured have lower rates of screening mammography use and bear a disproportionate burden of disease.

OBJECTIVES

The Breast Cancer Education Project (BCEP) was created to address the needs of medically underserved women in Cook County through high-quality breast cancer screening, education and support. The BCEP also provides a service-learning opportunity in which medical students can provide a valuable health service while obtaining important skills that enable them to work more effectively within medically underserved communities.

CONCLUSION

The BCEP is an innovative collaboration between academic medical centers, safety-net health systems, community-based organizations and public health organizations. It represents a model for addressing issues of disparate access to breast cancer screening within vulnerable communities that contribute to higher breast cancer mortality.

Mobile mammography: assessment of self-referral in reaching medically underserved women

BACKGROUND

Mobile mammography can be useful in reaching medically underserved women. However, it is not known whether self-referral for mobile mammography is the best approach for reaching the most vulnerable populations.

OBJECTIVES

1) To describe the community outreach patterns of a county-sponsored mobile mammography unit, 2) To characterize the follow-up patterns for women with abnormal screening mammograms, and 3) to identify reasons why women screened on mobile units seek follow-up care outside of the safety-net system.

METHODS

We prospectively followed women aged > or = 40 years who received mobile mammograms using electronic records and medical chart review, and surveyed women who had no evidence of diagnostic follow-up. We also reviewed administrative records to determine outreach patterns of the mobile mammography units.

RESULTS

Seventy-five percent of mobile visits were with community-based organizations or community health centers. At least one quarter of women chose to follow-up outside of the safety-net for evaluation of abnormal screening mammograms. Of these, nearly 40% reported having insurance or a private physician as the primary reason for having diagnostic evaluation outside of the public hospital system.

CONCLUSIONS

Despite serving primarily community-based facilities, self-referral for mobile mammography may not optimally target medically underserved women most in need of breast cancer screening.

Disparities in screening mammography. Current status, interventions and implications

OBJECTIVE

This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization.

DESIGN

We reviewed medline and other databases as well as relevant bibliographies.

MAIN RESULTS

The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities.

CONCLUSIONS

The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.

Screening mammography in the elderly: a review of the issues

Women age 70 and older have the highest incidence and mortality from breast cancer of any age group. Despite this increased burden of disease, studies show that older women are the least likely to be screened for breast cancer. Barriers to routine mammography in this population include transportation and logistical issues, psychosocial barriers, low literacy levels, and institutional barriers. A variety of interventions, such as community health educators and mobile mammography, have been effective at increasing screening mammography among older women. Although limited, studies have reported that screening mammography reduced breast cancer mortality among women age 65 and older. Research supports continued screening with mammography for elderly women as long as their health is not significantly compromised by comorbid illness, and most organizational guidelines support screening mammography in healthy elderly women. Ultimately, the decision to continue breast cancer screening should be made by the patient and her physician after carefully weighing the risks and benefits of the procedure, which generally become more favorable as women age.

X-ray crystallography of DNA-drug complexes

Here we have stressed important differences between protein and DNA crystallography. Crystal growth and data collection methodologies are not directly transferable between the two subfields. In addition, we note that analysis of symmetry and packing of DNA crystals can be useful and a uniquely aesthetic exercise.

Effects of cationic charge on three-dimensional structures of intercalative complexes: structure of a bis-intercalated DNA complex solved by MAD phasing

We characterize intercalative complexes as either "high charge" and "low charge". In low charge complexes, stacking interactions appear to dominate stability and structure. The dominance of stacking is evident in structures of daunomycin, nogalamycin, ethidium, and triostin A/echinomycin. By contrast in a DNA complex with the tetracationic metalloporphyrin CuTMPyP4 [copper (II) meso-tetra(N-methyl-4-pyridyl)porphyrin], electrostatic interactions appear to draw the porphyrin into the duplex interior, extending the DNA along its axis, and unstacking the DNA. Similarly, DNA complexes of tetracationic ditercalinium and tetracationic flexi-di show significant unstacking. Here we report x-ray structures of complexes of the tetracationic bis-intercalator D232 bound to DNA fragments d(CGTACG) and d(BrCGTABrCG). D232 is analogous to ditercalinium but with three methylene groups inserted between the piperidinium groups. The extension of the D232 linker allows it to sandwich four base pairs rather than two. In comparison to CuTMPyP4, flexi-di and ditercalinium, stacking interactions of D232 are significantly improved. We conclude that it is not sufficient to characterize intercalators simply by net charge. One anticipates strong electrostatic forces when cationic charge is focused to a small volume or region near DNA and so must consider the extent to which cationic charge is focused or distributed. In sum, ditercalinium, with a relatively short linker, focuses cationic charge more narrowly than does D232. So even though the net charges are equivalent, electrostatic charges are expected to be of greater structural significance in the ditercalinium complex than in the D232 complex.

Structure of DNA-porphyrin complex

We report the 2.4 A resolution X-ray structure of a complex in which a small molecule flips a base out of a DNA helical stack. The small molecule is a metalloporphyrin, CuTMPyP4 [copper(II) meso-tetra(N-methyl-4-pyridyl)porphyrin], and the DNA is a hexamer duplex, [d(CGATCG)]2. The porphyrin system, with the copper atom near the helical axis, is located within the helical stack. The porphyrin binds by normal intercalation between the C and G of 5' TCG 3' and by extruding the C of 5' CGA 3'. The DNA forms a distorted right-handed helix with only four normal cross-strand Watson-Crick base pairs. Two pyridyl rings are located in each groove of the DNA. The complex appears to be extensively stabilized by electrostatic interactions between positively charged nitrogen atoms of the pyridyl rings and negatively charged phosphate oxygen atoms of the DNA. Favorable electrostatic interactions appear to draw the porphyrin into the duplex interior, offsetting unfavorable steric clashes between the pyridyl rings and the DNA backbone. These pyridyl-backbone clashes extend the DNA along its axis and preclude formation of van der Waals stacking contacts in the interior of the complex. Stacking contacts are the primary contributor to stability of DNA. The unusual lack of van der Waals stacking contacts in the porphyrin complex destabilizes the DNA duplex and decreases the energetic cost of local melting. Thus extrusion of a base appears to be facilitated by pyridyl-DNA steric clashes.

Asymmetry and dynamics in bis-intercalated DNA

The bis-intercalator ditercalinium (NSC 366241), composed of two 7 H-pyridocarbazoles linked by a bis(ethylpiperidinium), binds to DNA with a binding constant greater than 10(7) M-1. One distinctive aspect of the 3-D X-ray structure of a DNA-ditercalinium complex is its asymmetry. We propose here that the activity of ditercalinium may be related to structural polymorphism and dynamic conversion between conformers. It was previously reported that activity is closely related to linker composition. Activity increases with increasing conformational restraints of the linker. We suggest these conformational restraints can lead to asymmetry in DNA complexes and that this asymmetry results directly in structural polymorphism. Using the Cambridge Structural Database (CSD) as a source of information about chemical fragments that are analogous to the linker of ditercalinium, we have explored the conformational space available to ditercalinium. The results indicate that the linker is highly constrained and that the DNA complex is intrinsically asymmetric. We propose a reasonable mechanism of ring reversal that is consistent with the conformations of analogous fragments within the CSD.

X-ray structure of a DNA decamer containing 7,8-dihydro-8-oxoguanine

We have determined the x-ray structure of a DNA fragment containing 7,8-dihydro-8-oxoguanine (G(O)). The structure of the duplex form of d(CCAGOCGCTGG) has been determined to 1.6-A resolution. The results demonstrate that GO forms Watson-Crick base pairs with the opposite C and that G(O) is in the anti conformation. Structural perturbations induced by C.G(O)anti base pairs are subtle. The structure allows us to identify probable elements by which the DNA repair protein MutM recognizes its substrates. Hydrogen bond donors/acceptors within the major groove are the most likely element. In that groove, the pattern of hydrogen-bond donors/acceptors of C.G(O)anti is unique. Additional structural analysis indicates that conversion of G to G(O) would not significantly influence the glycosidic torsion preference of the nucleoside. There is no steric interaction of the 8-oxygen of G(O) with the phospho-deoxyribose backbone.

DNA distortion in bis-intercalated complexes

The bis-intercalators Flexi-Di and ditercalinium are synthetic dimers that bis-intercalate into DNA and cause cell death in prokaryotes from futile and abortive repair of DNA. Each is composed of two 7H-pyridocarbazole units and a linker. Flexi-Di has a flexible spermine-like linker while ditercalinium has a rigid bis(ethylpiperidinium) linker. This report, describing the 2.5-A X-ray structure of Flexi-Di complexed with [d(BrCGCG)]2, appears to be the first report of a three-dimensional structure of a DNA complex with a bis-intercalator with a flexible linker. DNA complex formation with a ditercalinium analog having a flexible linker was not anticipated to yield unstacked and bent DNA as was observed in the previously reported ditercalinium.[d(CGCG)]2 complex. Surprisingly, the DNA in the Flexi-Di complex is bent to a degree exceeding that of the ditercalinium complex. A comparison of the DNA complexes of Flexi-Di and ditercalinium has allowed us to propose a mechanism by which these bis-intercalators distort DNA. We propose that this class of bis-intercalators pulls the internal base pairs into the major groove and pushes the external base pairs into the minor groove. The result is a bend toward the minor groove. It appears that hydrogen bonds between the linker and the internal guanines effectively pull the central base pairs of the complex out into the major groove. At the external regions of the complex, stacking interactions between the chromophores and terminal base pairs effectively push the terminal base pairs into the minor groove. The result of this push/pull combination is to bend the DNA.

Water ring structure at DNA interfaces: hydration and dynamics of DNA-anthracycline complexes

In crystallographic structures of biological macromolecules, one can observe many hydration rings that originate at one water molecule, pass via hydrogen bonds through several others, and return to the original water molecule. Five-membered water rings have been thought to occur with greater frequency than other ring sizes. We describe a quantitative assessment of relationships between water ring size and frequency of occurrence in the vicinity of nucleic acid interfaces. This report focuses on low-temperature X-ray crystallographic structures of two anthracyclines, adriamycin (ADRI) and daunomycin (DAUN), bound to d(CGATCG) and on several DNA structures published previously by others. We have obtained excellent low-temperature (-160 degrees C, LT) X-ray intensity data for d(CGATCG)-adriamycin and d(CGATCG)-daunomycin with a multiwire area detector. The LTX-ray data sets contain 20% (daunomycin, LT-DAUN) and 35% (adriamycin, LT-ADRI) more reflections than were used to derive the original room-temperature (15 degrees C) structures [Frederick, C.A., Williams, L.D., Ughetto, G., van der Marel, G. A., van Boom, J.H., Rich, A., & Wang, A.H.-J. (1990) Biochemistry 29, 2538-2549]. The results show that five-membered water rings are not preferred over other ring sizes. This assessment is consistent with our observation of broad dispersion W-W-W angles (sigma = 20 degrees). In addition, we report that the thermal mobility, distinct from the static disorder, of the amino sugar of daunomycin and adriamycin is significantly greater than that of the rest of the complex. This mobility implies that if the central AT base pair is switched to a CG base pair, there should be a low energy cost in avoiding the guanine amino group. The energy difference (for the sugar-binding preference) between d(CGTACG) and d(CGCGCG) could be considerably less than 20 kcal/mol, a value proposed previously from computation.

Energy cost of lactation, and energy balances of well-nourished Dutch lactating women: reappraisal of the extra energy requirements of lactation

At 9 wk postpartum the difference in energy intake of 40 lactating (2440 +/- 430 kcal/d) and 16 nonlactating women (1680 +/- 400 kcal/d) was 760 kcal/d but decreased to 550 kcal/d when adjusted for habitual intakes and body weight. Energy cost of lactation amounted to 650 kcal/d (breast-milk production, 745 +/- 130 g/d). When compared with nonlactating counterparts, the lactating women mainly achieved energy balance by eating more. Sixteen of the 40 lactating women were also studied at 56 wk. Their cost of lactation at 5-13 wk was 630 kcal/d (breast-milk production, 720 +/- 124 g/d); these women met their energy cost of lactation by eating more (415 kcal/d); by tissue mobilization (35 kcal/d), and by reducing energy expenditure (180 kcal/d). The present study helps in the understanding of how well-nourished women with an adequate lactational performance may cope in everyday life with the energy stress of lactation, and suggests that current recommendations of energy needs during lactation are too high.

Energy cost of physical activity throughout pregnancy and the first year postpartum in Dutch women with sedentary lifestyles

Basal metabolic rate (BMR), activity pattern, and energy costs of some daily activities were measured in 25 Dutch women throughout pregnancy and the first year postpartum. Physical activity index (PAI), which refers to daily energy expenditure expressed as a multiple of BMR, was calculated from activity-pattern data and activity costs. Mean PAIs (+/- SD) throughout pregnancy, during the first 6 mo postpartum, and at 1 y postpartum were 1.48 +/- 0.08, 1.49 +/- 0.07, and 1.53 +/- 0.10 X BMR, respectively. Because measured BMR at 1 y postpartum was 1440 +/- 168 kcal/d, costs for physical activity in pregnancy and the first 6 mo postpartum were, respectively, approximately 70 and approximately 50 kcal/d lower than at 1 y postpartum. For women with sedentary lifestyles the energy saved during pregnancy and lactation because of decreased physical activity and decreased costs of activities will be limited.

Energy cost of walking at a fixed pace and self-paced before, during, and after pregnancy

Body weight, basal metabolic rate (BMR), and treadmill metabolic rate (TMR) (3.9 km/h, no elevation) were measured in 39 women at 12, 24, and 36 wk gestation and at 9 wk postpartum. Prepregnancy measurements were also made on 15 of the women. TMR at 36 wk (3.65 +/- 0.50 kcal/min) was significantly higher than at 24 wk (3.38 +/- 0.43 kcal/min) or at 9 wk postpartum (3.38 +/- 0.43 kcal/min). Net energy cost (TMR minus BMR) at 36 wk gestation (2.42 +/- 0.40 kcal/min) was not different from prepregnancy or postpartum values but was significantly higher than at 12 wk (2.28 +/- 0.39 kcal/min) and 24 wk (2.28 +/- 0.37 kcal/min) gestation. In eight women the energy cost of self-paced walking on a treadmill was measured. The absolute and net energy cost decreased sharply from 6 to 12 wk gestation (by 8% and 11%, respectively) but remained unchanged afterwards. The data suggest that in the energy requirements for pregnant women no additional allowance need be made for physical activity, even if a woman's activity pattern includes a substantial amount of externally paced work.

Body fat mass and basal metabolic rate in Dutch women before, during, and after pregnancy: a reappraisal of energy cost of pregnancy

Body weight, fat mass, and basal metabolic rate were measured longitudinally from early pregnancy until 2 mo postpartum in 57 healthy Dutch women; 23 of whom were also studied before pregnancy. Weight gain over pregnancy was 11.8 +/- 3.7 kg and weight gain from 12 wk gestation to delivery was 10.3 +/- 3.8 kg. Birth weights and placental weights were 3458 +/- 527 and 657 +/- 114 g, respectively. Gain in maternal fat stores over pregnancy was 2.0 +/- 2.6 kg and difference in fat mass from 12 wk gestation to 5 wk postpartum was 1.2 +/- 2.2 kg. The energy equivalent of the gain in fat stores, including costs of synthesizing, can be estimated as 22,000 kcal. The cumulative increment in basal metabolism over pregnancy was 34,350 +/- 30,000 kcal. When the energy equivalent of the gain in tissue other than fat stores is assumed to be approximately 11,750 kcal, total energy cost of pregnancy is at 68,100 +/- 38,560 kcal.

New equations for estimating body fat mass in pregnancy from body density or total body water

The equations for estimating fat mass from body density or total body water are not appropriate for application in pregnancy, because the underlying assumptions with respect to density and composition of fat-free mass do not hold for pregnancy. Representative values have been derived from literature data for density and water content of maternal fat-free mass throughout pregnancy. Using these values we developed a method that provides new equations for estimating fat mass from body density or total body water for any desired stage of pregnancy. The validity of the new equations based on body density is discussed using data on body weight and body density obtained from a longitudinal study on well-nourished Dutch pregnant women. Because the new equations result in more valid estimates of maternal body fat mass, we suggest that they be used in studies on energy balance in pregnancy.

Energy requirements of pregnancy in The Netherlands

57 healthy Dutch women were studied longitudinally from early pregnancy until 2 months post partum. Regular measurements were made of energy intake in food, basal metabolic rate, body weight and body fat mass, and levels of physical activity. Some data were obtained before conception in 23 women. The energy cost of pregnancy calculated as the energy deposited as new tissues plus the associated increase in basal metabolism amounted to 286 MJ (1020 kJ/day), which is only 11% lower than the theoretical estimate of requirements of 323 MJ (1 MJ = 239 kcal). Energy intake throughout the first 10 wk of pregnancy was identical to that before pregnancy. Energy intake was only 200 kJ/day higher in late than in early pregnancy (not significant), and the cumulative increase in energy intake over pregnancy was estimated as 22 MJ (about 80 kJ/day). There is, therefore, an energy gap in pregnancy of about 940 kJ/day. It is proposed that the main mechanisms by which the pregnant body is able to save energy and to bridge the energy gap are by adjustments to physical activity and an increase in work efficiency and an adaptation of the metabolic response to food. Savings on physical activity by behavioural adaptations will not exceed 355 kJ/day.