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This work aimed to evaluate the effects of whey protein concentrate admixtured of curcumin on metabolic control, inflammation and oxidative stress in Wistar rats submitted to exhaustive exercise. A total of 48 male rats were divided into 6 experimental groups (n = 8): standard diet group (AIN-93M); standard diet submitted to exhaustion test group (AIN-93M ET); whey protein concentrate admixtured of curcumin group (WPC + CCM); WPC + CCM submitted to exhaustion test group (WPC + CCM ET); CCM group, and CCM subjected to exhaustion test group (CCM ET). The swimming exhaustion test was performed after 4 weeks of experiment. The consumption of WPC + CCM as well as isolated CCM did not alter the biometric measurements, the animals’ food consumption and the hepatic and kidney function, as well as the protein balance of the animals (p>0.05), but reduced the glycemia and the gene expression of TNF- α and IL-6, and increased the expression of IL-10 (p<0.05). The animals that were submitted to the exhaustion test (AIN-93M ET) showed higher AST values when compared to the animals that did not perform the exercise (AIN-93 M) (p<0.05). WPC + CCM reduced the concentration of nitric oxide, carbonylated protein and increased the concentration of catalase (p<0.05). Both (WPC + CCM and CCM) were able to increase the concentrations of superoxide dismutase (p<0.05). We concluded that the WPC admixtured of CCM represents a strategy capable of decreasing blood glucose and oxidative and inflammatory damage caused by exhaustive physical exercise in swimming.
Trichomonas vaginalis is a parasite of the human urogenital tract and the causative agent of trichomoniasis, a sexually transmitted disease of worldwide importance. This parasite is usually found as a motile flagellated trophozoite. However, when subjected to stressful microenvironmental conditions, T. vaginalis trophozoites can differentiate into peculiar cyst-like stages, which exhibit notable physiological resistance to unfavourable conditions. Although well documented in morphological and proteomic terms, patterns of gene expression changes involved in the cellular differentiation into cyst-like stages are mostly unknown. The real-time reverse transcription polymerase chain reaction (RT-qPCR) is recognized as a sensitive and accurate method for quantification of gene expression, providing fluorescence-based data that are proportional to the amount of a target RNA. However, the reliability of relative expression studies depends on the validation of suitable reference genes, which RNAs exhibit a minimum of variation between tested conditions. Here, we attempt to determine suitable reference genes to be used as controls of invariant expression during cold-induced in vitro differentiation of T. vaginalis trophozoites into cyst-like forms. Furthermore, we reveal that the mRNA from the meiotic recombinase Dmc1 is upregulated during this process, indicating that cryptic sexual events may take place in cyst-like stages of T. vaginalis.
Amidst widespread occurrence of herbicide-resistant weeds in the United States, the use of PRE herbicides and cover crops have resurged once again as important strategies for weed management in cropping systems. The objective of this experiment was to evaluate the length of soil residual weed control from PRE soybean herbicides and the detrimental impact of these herbicides on cover crop species using field treated soil in greenhouse bioassays. Greenhouse bioassays were conducted using soil from field experiments conducted in 2018 and 2019 at Arlington and Lancaster, WI. PRE herbicides consisted of imazethapyr, chlorimuron-ethyl, and cloransulam-methyl (acetolactate synthase [ALS]-inhibitors), metribuzin (photosystem II [PSII]-inhibitor), sulfentrazone, flumioxazin, and saflufenacil (protoporphyrinogen oxidase [PPO]-inhibitors), acetochlor, S-metolachlor, dimethenamid-P, and pyroxasulfone (very long-chain fatty acid [VLCFA]-inhibitors), and a nontreated control. Greenhouse bioassays were conducted using soil (0-10 cm depth) sampled at 0, 10, 20, 30, 40 and 50 d after treatment (DAT). Palmer amaranth and giant foxtail (weeds), and radish and cereal rye (cover crops) were used as bioindicators of herbicide levels in the soil. Bioassay results showed extended soil residual control of Palmer amaranth with sulfentrazone and pyroxasulfone; extended residual control of giant foxtail was observed with pyroxasulfone and S-metolachlor. Chlorimuron-ethyl and metribuzin were the most injurious herbicides to radish and cereal rye shortly after application, respectively, but minimal injury was observed from soil samples collected 50 DAT indicating the use of PRE and fall seeded cover crops in southern Wisconsin can be compatible. These results can support growers and practitioners with selection of effective PRE herbicides for Palmer amaranth and giant foxtail control and reduced impact on fall seeded radish and cereal rye cover crops altogether leading to more effective, diverse and sustainable weed management programs.
Weedy rice (Oryza sativa L.) is one of the most troublesome weeds affecting rice (Oryza sativa L.) production in many countries. Weedy rice control is difficult in rice fields because the weed and crop are phenotypically and morphologically similar. Weedy rice can be a source of genetic diversity to cultivated rice. Thus, this study aimed to characterize the morphological diversity of weedy rice in Southern Brazil. Qualitative and quantitative traits of 249 accessions from eight rice growing mesoregions in Rio Grande do Sul (RS) and Santa Catarina (SC) states were analyzed. For each accession, 24 morphological descriptors (14 qualitative and 10 quantitative) were evaluated. All the 249 accessions from RS and SC are of indica lineage. Considering all the phenotypic traits evaluated, the accessions separated into 14 distinct groups. One of the largest groups consisted of plants that were predominantly tall and with green leaves, intermediate shattering, and variable in flowering time. Distinct subgroups exist within larger clusters, showing discernable phenotypic diversity within the main clusters. The variability in flowering time was high (77 to 110 d after emergence), indicating high potential for flowering synchrony with rice cultivars and, consequently, gene flow. This indicates the need to remove escapes when planting herbicide-resistant rice. Thus, weedy rice populations in Southern Brazil are highly diverse and this diversity could result in variable response to weed management.
The double burden of malnutrition (DBM) has been described in many low-/middle-income countries. We investigated food addiction, thyroid hormones, leptin, the lipid/glucose profile and body composition in DBM children/adolescents. Subjects were allocated into groups according to nutritional status: control (C, n 28), weight excess (WE, n 23) and DBM (WE plus mild stunting, n 22). Both the DBM and WE groups showed higher mean insulin concentrations than the control (DBM = 57·95 (95 % CI 47·88, 70·14) pmol/l, WE = 74·41 (95 % CI 61·72, 89·80) pmol/l, C = 40·03 (95 % CI 34·04, 47·83) pmol/l, P < 0·001). WE and DBM showed more food addiction symptoms than the control (3·11 (95 % CI 2·33, 3·89), 3·41 (95 % CI 2·61, 4·20) and 1·66 (95 % CI 0·95, 2·37)). In DBM individuals, addiction symptoms were correlated with higher body fat and higher insulin and leptin levels. These data provide preliminary evidence consistent with the suggestion that DBM individuals have a persistent desire to eat, but further studies are required to confirm these results in a larger study. These hormonal changes and high body fat contribute to the development of diabetes in long term.
The recently discovered massive and stockwork sulphide mineralization of Semblana-Rosa Magra and Monte Branco, situated ESE of the Neves–Corvo volcanogenic massive sulphide (VMS) deposit in the Iberian Pyrite Belt (IPB) is presented. Geological setting and tectonic model is discussed based on proxies such as palynostratigraphy and U–Pb zircon geochronology. The mineralization is found within the IPB Volcano-Sedimentary Complex (VSC) Lower sequence, which includes felsic volcanic rocks (rhyolites) with U–Pb ages in zircons of 359.6 ± 1.6 Ma, and black shales of the Neves Formation of late Strunian age. Massive sulphides are enveloped by these shales, implying that felsic volcanism, mineralization and shale sedimentation are essentially coeval. This circumstance is considered highly prospective, as it represents an important exploration vector to target VMS mineralization across the IPB, in areas where the Lower VSC sequence is present. The Upper VSC sequence, with siliciclastic and volcanogenic sedimentary rocks of middle–late Visean age, shows no massive mineralization but a late Tournaisian (350.9 ± 2.3 Ma) volcanism with disseminated sulphides was also identified. Nevertheless, stratigraphic palynological gaps were found within the Strunian and in the Tournaisian sediments, between the Lower and Upper VSC sequences, reflecting probable erosion and uplift mechanisms linked with extensional tectonics. The Semblana and Monte Branco deposits and the Rosa Magra stockwork are enclosed by tectonic sheets that dismembered the VSC sequence in a fold-and-thrust tectonic complex, characteristic of the NE Neves–Corvo region. The methodologies used allow a geological comparison between Neves–Corvo and other IPB mine regions such as Lousal–Caveira, Herrerias, Tharsis and Aznalcollar.
To investigate the shifts and factors associated with different scenarios resulting from the prevalence of child stunting and overweight in Brazilian municipalities.
This is an ecological study using municipality-level panel data of stunting and overweight prevalence and socio-economic characteristics from 2008 to 2014. The municipalities were classified according to the WHO-UNICEF prevalence thresholds for stunting and overweight and were categorised into four nutritional scenarios: no burden (prevalence of stunting < 20 % and overweight < 10 %), stunting burden (prevalence of stunting ≥ 20 % and overweight < 10 %), overweight burden (prevalence of stunting < 20 % and overweight ≥ 10 %) and double burden (prevalence of stunting ≥ 20 % and overweight ≥ 10 %).
Totally, 4443 Brazilian municipalities.
Aggregated data of children under 5 years old enrolled in the Brazil’s conditional cash transfer programme (Bolsa Família).
A mean reduction from 14·2 % to 12·7 % in the prevalence of stunting and an increase from 17·2 % to 18·4 % in the prevalence of overweight were observed. The predominant scenarios were overweight burden and double burden. The odds of both scenarios increased with higher gross domestic product (GDP) per capita and decreased with higher unemployment rates. Stunting and double burden decreased with higher expected years of schooling, and stunting burden increased with household crowding.
Our findings indicate an advanced nutrition transition stage in Brazil, associated mainly with municipal GDP per capita growth, which has contributed to increasing the burden of overweight alone or coexisting with stunting (double burden) among children in the most socio-economically vulnerable strata of the population.
Background:Stenotrophomonas maltophilia is an emerging pathogen responsible for high morbidity and mortality rates. Hospital infections caused by this bacteria, especially in intensive care centers, are concerning for the health system, given that the microorganism is multidrug resistant to most antimicrobials available. Objective: Therefore, the present study is built from an analysis of the variables related to nosocomial infections caused by S. maltophilia in hospitals in Brazil, to display points of major concern. Methods: We used the data collected by the Infection Prevention and Control Service to clarify the incidence rate of Stenotrophomonas maltophilia in Brazilian hospitals as well as the gross lethality of these infections and the profiles of infected patients. We collected and analyzed epidemiological data from 10 hospitals in Brazil for the period July 2014 to June 2019 according to the CDC NHSN protocol. Results: In 5 years, 93 Stenotrophomonas maltophilia infections were diagnosed in the hospitals analyzed. Overall, 61 occurred in men (66%) and 32 occurred in women (34%). Furthermore, 47 cases (51%) occurred in adult ICUs; 19 cases (20%) followed zascular surgery; 9 (10%) cases occurred in the neonatal ICU; 7 (8%) cases were from the medical clinic; and 11 (12%) were from other clinics. The incidence rate was 1.2 cases for 10,000 hospitalizations, ranging from 0.0 to 2.8 (Fig. 1). Patients’ ages ranged from 0 to 90 years, with a mean of 55 years (SD, 26 years) and a median of 64 years. Time between admission and diagnosis of infection was 1 to 102 days, with a mean of 24 days (SD, 21 days) and a median of 17 days. The gross lethality for S. maltophilia infection was 43 of 93 (46%) (95% CI, 35.8%–56.9%). The frequencies of specific infections were as follows (Fig. 2): pneumonia, 26 (28%); tracheobronchitism, 22 (24%); primary bloodstream infection, 18 (19%); skin and soft-tissue infection, 13 (14%); local infection, 7 (8%); vascular access infection, 3 (3%); urinary tract infection, 2 (2%); gastrointestinal infection, 1 (1%); and eye, nose, throat, and mouth infections, 1 (1%). Conclusions:Stenotrophomonas maltophilia infection is a rare and highly lethal event that usually occurs after 2 weeks of hospitalization. The most affected region is the respiratory tract, with a higher incidence in patients aged >60 years or in the ICU. Early and accurate investigations of multiresistant microorganisms in a hospital setting are needed to reduce patient morbidity and mortality.
We have synthesized off-stoichiometric Ni40Cu10Mn35Ti15 all-d-metal Heusler alloy with a B2 cubic crystal structure by an arc melting process and investigated its structural, magnetic, electronic, thermal, and mechanical properties under the influence of a single-step thermal annealing. The compound exhibits an antiferromagnetic ordering accompanied by thermal hysteresis indicating a first-order magneto-structural transition. Curie–Weiss molecular field analysis reveals the presence of ferromagnetic interactions competing with long-range antiferromagnetic ordering. Thermal annealing leads to the appearance of a heat capacity sharp peak around antiferromagnetic transition. Electrical resistivity measurements display abrupt changes close to the magneto-structural transition revealing the strong coupling among spin, lattice, and charge degrees of freedom characteristic of a martensitic transition (MT). We have also evaluated its mechanical properties from microhardness measurements, and the results indicate that this alloy exhibits ductile behavior. The occurrence of MT associated with improved ductility is an essential combination for technological application as shape-memory alloys.
Medicinal plants have been the focus of several studies due to their nematicide properties which can be used to control nematodes in sheep. No study has examined the morphological effects of Cymbopogon citratus on nematodes. Thus, this study evaluated the chemical composition, nematicidal activity and effects of C. citratus extracts on the morphology of eggs and infective larvae (L3) of sheep. Aqueous and methanolic extracts and fractions of C. citratus were obtained and analysed in vitro. The C. citratus extracts were effective against Haemonchus spp. and Trichostrongylus spp. larvae and eggs. Ten fractions were obtained from C. citratus, six of which had high ovicidal activity at 1000 μg mL−1, and two fractions had high activity at all tested concentrations. The phytochemical analysis identified the presence of compounds such as terpenoids, various ketones, esters, and fatty acids. The ultrastructural analysis showed deformations of the cuticle and wilting along the body of the nematodes at all concentrations. The muscular layer, intestinal cells and the mitochondria profile showed damage compared to the typical pattern. Ultra-thin sections of eggs treated with methanolic fractions of C. citratus presented modifications. This study showed the biological activity and effects of C. citratus on the gastrointestinal nematodes in sheep.
Our objectives were to identify genes of the multi-drug efflux system and to evaluate the antimicrobial activities of polypyrrole nanoparticles (PPy-NPs) and aqueous extract of Moringa oleifera against Staphylococcus spp. isolated from dairy farms in Northeast Brazil. Initially, 162 Staphylococcus spp. isolates were subjected to in vitro antimicrobial sensitivity tests. Of these, 35 presented antimicrobial multi-drug resistance phenotypes. These 35 isolates were then referred for the detection of norA, norB, norC, msrA, mgrA, tet-38, and lmrS genes, all of which feature in multi-drug efflux systems. In the isolates carrying the genes, the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of PPy-NPs and Moringa oleifera aqueous extract were determined. In the molecular analysis of the 35 isolates norA, norC, tet-38, and msrA genes were detected and for the other genes norB, lmrS and mgrA there was no amplification. Antimicrobial activity was verified of PPy-NPs and aqueous extract of Moringa oleifera in Staphylococcus spp. carrying multi-drug efflux system genes. We concluded that there are multi-drug efflux system genes present in the Staphylococcus spp. from the agricultural environment in Northeast Brazil, and that aqueous extract of Moringa oleifera and PPy-NPs show bactericidal activity against these isolates.
The study described in this Research Communication investigated the genotypic and phenotypic profiles of resistance to beta-lactams and other antimicrobials in non-aureus Staphylococci (NAS) isolated from buffalo, goat and sheep mastitis in the Northeast region of Brazil. A total of 190 isolates were analyzed and 42.3, 43.9 and 23.6% of them were positive for blaZ gene in buffalo, goat and sheep, respectively. Regarding the animal groups, in goats, amoxicillin was the antimicrobial with highest resistance index (72.7%), followed by penicillin G in buffaloes (51.9%) and ampicillin in sheep (43.1%). With regard to multiple antimicrobial resistance, 30.8% of NAS isolates from buffalo milk samples, 25.8% from goats and 25.0% from sheep presented multidrug-resistance. In the minimum inhibitory concentration (MIC) technique, amoxicillin MIC50 and MIC90 were 64 and 128 μg/ml, respectively, among isolates of the three animal species. In conclusion, high rates of resistance to beta-lactams are presented among NAS isolated from mastitis cases in buffaloes, goats and sheep in Northeast region of Brazil. These results provide an alert to animal and human health researchers, suggesting that the frequency of NAS needs to be reduced because they carry resistance genes which might increase the existing levels of antimicrobial resistance.
Housekeeping genes (HKG) are paramount for accurate gene expression analysis during preimplantation development. Markedly, quantitative reverse transcription polymerase chain reaction (RT-qPCR) in ovine embryos currently lacks HKGs. Therefore, we tested 11 HKGs for RT-qPCR normalization during ovine parthenogenetic preimplantation development. Seven HKGs reached the qPCR efficiency threshold (97.20–105.96%), with correlation coefficients ranging from −0.922 to −0.998 and slopes from −3.22 to −3.59. GeNorm ranked glyceraldehyde 3-phosphate dehydrogenase (GAPDH) and TATA-binding protein (TBP) as the best HKG pair, while H3 histone, family 3A (H3F3A) was the third HKG. Relative gene expression was measured for zinc finger protein X-linked (ZFX) and developmental pluripotency-associated 3 (DPPA3) transcripts during ovine parthenogenetic preimplantation development. ZFX did not show any transcript abundance fluctuation among oocytes, cleavage-stage embryos, and morulae. DPPA3 transcript abundance was also similar among all developmental stages, therefore suggesting that it may not display a maternal gene expression profile. In silico analysis of ovine DPPA3 mRNA and protein showed high conservation to bovine orthologues. However, DPPA3 orthologues differed in regulatory motifs. In conclusion, GAPDH, TBP and H3F3A are stable HKGs in ovine parthenogenetic embryos and allow accurate RT-qPCR-based gene expression analysis.
The goal of this study was to evaluate the effects of thinning eucalyptus trees on yield and nutritive value of corn for silage and palisadegrass in a crop–livestock–forest integrated system and to evaluate the total aboveground biomass yield in systems with and without trees. Plant variables, as well as the incidence of photosynthetically active radiation (PAR) and soil moisture, were evaluated between October 2016 and March 2018 in São Carlos, Brazil, in a crop–livestock–forest and a crop–livestock system. In the crop–livestock–forest system, eucalyptus trees (Eucalyptus urograndis clone GG100) were planted in April 2011, in single rows, with 15 × 2 m spacing. In 2016, the trees were thinned, and the spacing was changed to 15 × 4 m. The treatments comprised measurements at 0.00, 3.75, 7.50, and 11.25 m from the trees of the North row in the integrated crop–livestock–forest (iCLF) system and integrated crop–livestock (iCL) system. Palisadegrass (Urochloa brizantha) was sown after harvesting the corn. Corn yields were similar between treatments, with an average of 13.6 Mg ha−1. Corn for silage presented a higher percentage of grain in total biomass in the crop–livestock–forest positions (41.4 and 42.1%) than in the crop–livestock system (35.6%). No differences in forage accumulation were observed. Crude protein content in corn for silage and palisadegrass was higher in the crop–livestock–forest treatments than in the crop–livestock system. Such results indicate that thinning was favorable to production in the crop–livestock–forest system. Total aboveground biomass yield was higher in the iCLF system, indicating better land use for this type of integrated system.
In previous studies, we have identified several families of 5-nitroindazole derivatives as promising antichagasic prototypes. Among them, 1-(2-aminoethyl)-2-benzyl-5-nitro-1,2-dihydro-3H-indazol-3-one, (hydrochloride) and 1-(2-acetoxyethyl)-2-benzyl-5-nitro-1,2-dihydro-3H-indazol-3-one (compounds 16 and 24, respectively) have recently shown outstanding activity in vitro over the drug-sensitive Trypanosoma cruzi CL strain (DTU TcVI). Here, we explored the activity of these derivatives against the moderately drug-resistant Y strain (DTU TcII), in vitro and in vivo. The outcomes confirmed their activity over replicative forms, showing IC50 values of 0.49 (16) and 5.75 μm (24) towards epimastigotes, 0.41 (16) and 1.17 μm (24) against intracellular amastigotes. These results, supported by the lack of toxicity on cardiac cells, led to better selectivities than benznidazole (BZ). Otherwise, they were not as active as BZ in vitro against the non-replicative form of the parasite, i.e. bloodstream trypomastigotes. In vivo, acute toxicity assays revealed the absence of toxic events when administered to mice. Moreover, different therapeutic schemes pointed to their capability for decreasing the parasitaemia of T. cruzi Y acute infected mice, reaching up to 60% of reduction at the peak day as monotherapy (16), 79.24 and 91.11% when 16 and 24 were co-administered with BZ. These combined therapies had also a positive impact over the mortality, yielding survivals of 83.33 and 66.67%, respectively, while untreated animals reached a cumulative mortality of 100%. These findings confirm the 5-nitroindazole scaffold as a putative prototype for developing novel drugs potentially applicable to the treatment of Chagas disease and introduce their suitability to act in combination with the reference drug.
Several studies have shown that the Brazilian Northeast is a region with high rates of inbreeding as well as a high incidence of autosomal recessive diseases. The elaboration of public health policies focused on the epidemiological surveillance of congenital anomalies and rare genetic diseases in this region is urgently needed. However, the vast territory, socio-demographic heterogeneity, economic difficulties and low number of professionals with expertise in medical genetics make strategic planning a challenging task. Surnames can be compared to a genetic system with multiple neutral alleles and allow some approximation of population structure. Here, surname analysis of more than 37 million people was combined with health and socio-demographic indicators covering all 1794 municipalities of the nine states of the region. The data distribution showed a heterogeneous spatial pattern (Global Moran Index, GMI = 0.58; p < 0.001), with higher isonymy rates in the east of the region and the highest rates in the Quilombo dos Palmares region – the largest conglomerate of escaped slaves in Latin America. A positive correlation was found between the isonymy index and the frequency of live births with congenital anomalies (r = 0.268; p < 0.001), and the two indicators were spatially correlated (GMI = 0.50; p < 0.001). With this approach, quantitative information on the genetic structure of the Brazilian Northeast population was obtained, which may represent an economical and useful tool for decision-making in the medical field.
The terminal phase of cancer represents a major crisis for the family system. Regardless of the caregiving role they undertake, family members are forced to address multiple impacts when facing the approaching death of their terminally ill loved one. International guidelines recognize the importance of integrating the family into a care plan. However, more needs to be known about how to deliver optimal family support. The purpose of this study is to review the current state of the art in family/caregiver-focused interventions of people with terminal cancer in palliative care.
For this purpose, an overview of the literature's systematic reviews on the topic was conducted to select Randomized Controlled Trials (RCTs) on family/caregiver-focused interventions.
Nine interventions were found in the systematic reviews of literature and meta-analysis. These family/caregiver-focused interventions were then thoroughly and critically analyzed. Despite the heterogeneity with regard to their characteristics, the interventions commonly focused on caregiving matters, were brief in duration, and delivered by non-mental health experts. The efficacy of such interventions was seen as modest.
Significance of results
Family/caregiver-focused interventions in palliative care remain a matter of concern and more research is needed to identify adequate and effective ways of helping families that face the crisis of terminal illness in the system.
Diet during pregnancy is related to several maternal and infant health outcomes; however, the relationship between maternal dietary glycaemic index (GI) and glycaemic load (GL) and gestational weight gain (GWG) or newborn birth weight is controversial. The purpose of the present study was to investigate the relationship between maternal dietary GI and GL and GWG and birth weight. A cohort of adult pregnant women with usual obstetric risk was followed in Botucatu, SP, Brazil. Two 24-h dietary recalls were collected in each gestational trimester (<14, 24–27, 31–34 weeks), one in person and the other by telephone. GI and GL were determined using the software Nutrition Data System for Research. GWG was obtained from medical records and evaluated as the weekly GWG between the second and third gestational trimesters. Newborn birth weight z-score in relation to gestational age was evaluated according to Intergrowth-21st Project recommendations. A multiple linear regression model, adjusted for potential confounders, showed a one-point increase in the GI resulted in a mean decrease of 12·9 (95 % CI –21·48, –4·24) g in weekly GWG; GL was not associated with this outcome. The birth weight z-score was not associated with GI (P = 0·763) or GL (P = 0·317). In conclusion, in a cohort of pregnant women considered at usual risk for obstetric complications, maternal dietary GI was negatively associated with weekly GWG in the second and third gestational trimesters. No association was observed between GL and GWG, and neither GI nor GL was associated with birth weight z-score.