Intake of Snacks and Sweets in a National Study of Built and Social Environments: the REasons for Geographic And Racial Differences in Stroke Study.

BACKGROUND: Few national studies across the United States' rural-urban continuum examine neighborhood effects on snacks and sweets intake among adults. OBJECTIVES: This study examines associations of urbanicity/rurality-tailored measures of food store availability and neighborhood socioeconomic status (NSES) with the intake of snacks and sweets in a national sample of middle and older age adults. METHODS: This cross-sectional study used food frequency questionnaire data collected in the REasons for Geographic And Racial Differences in Stroke study (N = 21,204). What We Eat in America food group categorizations guided outcome classification into 1 main category (total snacks and sweets) and 4 subcategories (savory snacks and crackers; sweet bakery products; candy and desserts; nutrition bars and low-fat snacks and sweets). NSES and food store availability were determined using geographic information systems. Food store availability was characterized as geographic access to primary food stores (e.g., supermarkets, supercenters, and select food retailers) in urbanicity/rurality-tailored neighborhood-based buffers. Multiple linear regression was used to predict each outcome. RESULTS: Living in neighborhoods with a high density of primary food stores was associated with 8.6%, 9.5%, and 5.8% lower intake of total snacks and sweets, sweet bakery products, and candy and desserts, respectively. Living in the highest NSES quartile was associated with 11.3%, 5.8%, and 18.9% lower intake of total snacks and sweets, savory snacks and crackers, and sweet bakery products, respectively. Depending on primary food store availability, higher household income was associated with significantly greater intake of nutrition bars and low-fat snacks and sweets. Living in a United States Department of Agriculture-defined food desert was not associated with intake. CONCLUSIONS: In a geographically diverse sample of middle and older age United States adults, living in neighborhoods with no primary food stores or neighborhoods of low-SES was associated with higher intake of total snacks and sweets and subgroups of snacks and sweets.

A longitudinal examination of objective neighborhood walkability, body mass index, and waist circumference: the REasons for Geographic And Racial Differences in Stroke study.

BACKGROUND: Studies have shown neighborhood walkability is associated with obesity. To advance this research, study designs involving longer follow-up, broader geographic regions, appropriate neighborhood characterization, assessment of exposure length and severity, and consideration of stayers and movers are needed. Using a cohort spanning the conterminous United States, this study examines the longitudinal relationship between a network buffer-derived, duration-weighted neighborhood walkability measure and two adiposity-related outcomes. METHODS: This study included 12,846 Black/African American and White adults in the REasons for Geographic And Racial Differences in Stroke study. Body mass index (BMI) and waist circumference (WC) were assessed at baseline and up to 13.3 years later (M (SD) = 9.4 (1.0) years). BMI and WC were dichotomized. Walk Score® was duration-weighted based on time at each address and categorized as Very Car-Dependent, Car-Dependent, Somewhat Walkable, Very Walkable, and Walker's Paradise. Unadjusted and adjusted logistic regression models tested each neighborhood walkability-adiposity association. Adjusted models controlled for demographics, health factors, neighborhood socioeconomic status, follow-up time, and either baseline BMI or baseline WC. Adjusted models also tested for interactions. Post-estimation Wald tests examined whether categorical variables had coefficients jointly equal to zero. Orthogonal polynomial contrasts tested for a linear trend in the neighborhood walkability-adiposity relationships. RESULTS: The odds of being overweight/obese at follow-up were lower for residents with duration-weighted Walk Score® values in the Walker's Paradise range and residents with values in the Very Walkable range compared to residents with values in the Very Car-Dependent range. Residents with duration-weighted Walk Score® values classified as Very Walkable had significantly lower odds of having a moderate-to-high risk WC at follow-up relative to those in the Very Car-Dependent range. For both outcomes, the effects were small but meaningful. The negative linear trend was significant for BMI but not WC. CONCLUSION: People with cumulative neighborhood walkability scores in the Walker's Paradise range were less likely to be overweight/obese independent of other factors, while people with scores in the Very Walkable range were less likely to be overweight/obese and less likely to have a moderate-to-high risk WC. Addressing neighborhood walkability is one approach to combating obesity.

Virtual audits of the urban streetscape: comparing the inter-rater reliability of GigaPan® to Google Street View.

BACKGROUND: Although previous research has highlighted the association between the built environment and individual health, methodological challenges in assessing the built environment remain. In particular, many researchers have demonstrated the high inter-rater reliability of assessing large or objective built environment features and the low inter-rater reliability of assessing small or subjective built environment features using Google Street View. New methods for auditing the built environment must be evaluated to understand if there are alternative tools through which researchers can assess all types of built environment features with high agreement. This paper investigates measures of inter-rater reliability of GigaPan®, a tool that assists with capturing high-definition panoramic images, relative to Google Street View. METHODS: Street segments (n = 614) in Pittsburgh, Pennsylvania in the United States were randomly selected to audit using GigaPan® and Google Street View. Each audit assessed features related to land use, traffic and safety, and public amenities. Inter-rater reliability statistics, including percent agreement, Cohen's kappa, and the prevalence-adjusted bias-adjusted kappa (PABAK) were calculated for 106 street segments that were coded by two, different, human auditors. RESULTS: Most large-scale, objective features (e.g. bus stop presence or stop sign presence) demonstrated at least substantial inter-rater reliability for both methods, but significant differences emerged across finely detailed features (e.g. trash) and features at segment endpoints (e.g. sidewalk continuity). After adjusting for the effects of bias and prevalence, the inter-rater reliability estimates were consistently higher for almost all built environment features across GigaPan® and Google Street View. CONCLUSION: GigaPan® is a reliable, alternative audit tool to Google Street View for studying the built environment. GigaPan® may be particularly well-suited for built environment projects with study settings in areas where Google Street View imagery is nonexistent or updated infrequently. The potential for enhanced, detailed imagery using GigaPan® will be most beneficial in studies in which current, time sensitive data are needed or microscale built environment features would be challenging to see in Google Street View. Furthermore, to better understand the effects of prevalence and bias in future reliability studies, researchers should consider using PABAK to supplement or expand upon Cohen's kappa findings.

Pathways to prevention: improving nonresident African American fathers' parenting skills and behaviors to reduce sons' aggression.

This study describes a test of the Fathers and Sons Program for increasing intentions to avoid violence and reducing aggressive behaviors in 8- to 12-year-old African American boys by enhancing the parenting skills satisfaction and parenting behaviors of their nonresident fathers. The study included 158 intervention and 129 comparison group families. Structural equation model results indicated that the intervention was effective for improving fathers' parenting skills satisfaction, which was positively associated with sons' satisfaction with paternal engagement. Sons' paternal engagement satisfaction was positively associated with their intentions to avoid violence. Although aggressive behaviors were lower for comparison group sons, the intervention effectively reduced sons' aggressive behaviors indirectly by enhancing fathers' parenting behaviors. Support for family-centered youth violence prevention efforts is discussed.

Body Mass Index Trajectories among the Healthy Communities Study Children: Racial/Ethnic and Socioeconomic Disparities in Childhood Obesity.

The purpose of this study is to identify statistically distinguishable trajectories of childhood body mass index (BMI), an important indicator of developmental status of children, and to provide a summary description of demographic characteristics of children based on these distinctive trajectories. Using data from the Healthy Communities Study (HCS), a large longitudinal dataset with oversamples of Hispanic and Black children across 130 communities in the USA, a group-based trajectory analysis approach was used to estimate trajectories of children based on their BMI-z scores. The three most distinguishable BMI trajectory groups identified for the HCS children show no marked increase or decrease in standardized BMI over an age range of 2 to 11. Approximately 28.5% of children were in a trajectory group with consistently obese BMI-z scores for their sex and age. The patterns of BMI trajectory groups identified for boys and girls are similar, but BMI-z scores for boys tend to be slightly higher than those for girls. These BMI trajectories are characterized by racial/ethnic and socioeconomic status disparities. Hispanic and Black children were more likely to be in the obese trajectory group than White children. Children with parents having less education, or children from low family income level, were more likely to be in the obese trajectory group than counterpart children. The findings suggest that BMI disparities exist from the early years of childhood and persist across childhood, with higher BMI associated with Black and Hispanic children as well as those from low socioeconomic status backgrounds.

Park Area and Physical Activity Among Children and Adolescents: Findings From the Healthy Communities Study.

BACKGROUND: There is currently a nationwide effort to bring parks and green spaces within a 10-minute walk of the home. We examined the association between park area within 1 km of a child's residence and self-reported park-specific physical activity (PA) along with accelerometer-derived moderate to vigorous physical activity (MVPA). METHODS: A subsample of K through eighth-grade youth (n = 493) from the Healthy Communities Study reported whether they engaged in park-specific PA during the last 24 hours and wore an accelerometer for up to 7 days. Park area was defined as the percentage of park land in a 1 km Euclidean buffer around the participant's residence, categorized into quintiles. Analysis consisted of logistic and linear regression modeling with interaction effects that controlled for clustering within communities. RESULTS: Regression models estimated greater park-specific PA for participants in the fourth and fifth quintiles of park land. Age, sex, race ethnicity, and family income were unrelated to park-specific PA. Accelerometer analysis indicated that total MVPA was unrelated to park area. Older children (ß = -8.73, P < .001) and girls (ß = -13.44, P < .001) engaged in less MVPA. Seasonality significantly predicted both park-specific PA and total MVPA. CONCLUSION: Increasing park area is likely to improve youth PA patterns, lending support for the 10-minute walk initiative.

Validity of self-rated hearing compared with audiometric measurement among construction workers.

BACKGROUND: A valid assessment of hearing status is important to detect hearing loss early and prevent further loss in noise-exposed individuals or older adults. Self-report is used widely in research and is often the only possible measure to evaluate hearing ability. OBJECTIVES: The aims of this study were to establish the level of validity of self-rated hearing by comparing it with the results of audiograms and to examine correlations and changes in self-rated and measured hearing status over time. METHODS: Survey and audiogram data collected from 403 construction workers at two different time points (Years 1 and 2) were used in the hearing protection intervention study. Self-rated hearing was assessed on a 5-point rating scale using a single question ("How do you rate your hearing?"). Hearing was measured via audiograms conducted at frequencies 0.5 through 8 kHz. Three pure-tone threshold average (PTA) indicators, PTA 0.5-2 kHz, PTA 0.5-3 kHz, and PTA 4-6 kHz, of the worse ear were used and compared with self-ratings at two time points. RESULTS: Percentage of agreement between the self-rated and measured hearing was lowest in PTA 4-6 kHz and highest in PTA 0.5-3 kHz for both years. Cohen's kappas showed fair to moderate (.25-.45) agreement. Sensitivity was higher (.82-.89) in the speech frequencies and lower (.51-.55) at higher frequencies. Specificity was better at higher frequencies than at lower frequencies (.83-.89 vs .68-.74). Although there was no appreciable change in self-rated hearing and limited change in measured hearing on all 3 indicators from Years 1 to 2, correlations between self-rated and measured hearing were higher in Year 2. DISCUSSION: A single-item question about an individual's hearing ability is moderately useful and valid to assess hearing loss and can be recommended for a population-based study only if audiograms are not available, but self-report hearing screening should not be considered an adequate substitute for the standardized audiometric test. Providing audiograms and feedback on the results apparently enhanced individuals' ability to judge their hearing status.

Nurse dose: linking staffing variables to adverse patient outcomes.

BACKGROUND: Inconsistent findings in more than 100 studies have made it difficult to explain how variation in nurse staffing affects patient outcomes. Nurse dose, defined as the level of nurses required to provide patient care in hospital settings, draws on variables used in staffing studies to describe the influence of many staffing variables on outcomes. OBJECTIVES: The aim of this study was to examine the construct validity of nurse dose by determining its association with methicillin-resistant Staphylococcus aureus (MRSA) infections and reported patient falls on a sample of inpatient adult acute care units. METHODS: Staffing data came from 26 units in Ontario, Canada, and Michigan. Financial and human resource data were data sources for staffing variables. Sources of data for MRSA came from infection control departments. Incident reports were the data source for patient falls. Data analysis consisted of bivariate correlations and Poisson regression. RESULTS: Bivariate correlations revealed that nurse dose attributes (active ingredient and intensity) were associated significantly with both outcomes. Active ingredient (education, experience, skill mix) and intensity (full-time employees, registered nurse [RN]:patient ratio, RN hours per patient day) were significant predictors of MRSA. Coefficients for both attributes were negative and almost identical. Both attributes were significant predictors of reported patient falls, and coefficients were again negative, but coefficient sizes differed. DISCUSSION: By conceptualizing nurse and staffing variables (education, experience, skill mix, full-time employees, RN:patient ratio, RN hours per patient day) as attributes of nurse dose and by including these in the same analysis, it is possible to determine their relative influence on MRSA infections and reported patient falls.

The role of the built environment, food prices and neighborhood poverty in fruit and vegetable consumption: An instrumental variable analysis of the moving to opportunity experiment.

The food environment has been associated with fruit and vegetable consumption, however many studies utilize cross-sectional research designs. This study examined 3,473 participants in the Moving to Opportunity experiment, who were randomized into groups that affected where they lived. The relationship between the built environment, food prices and neighborhood poverty, assessed over four to seven years, on fruit or vegetable consumption was examined using instrumental variable analysis. Higher food prices and neighborhood poverty were associated with lower fruit or vegetable consumption. Policies and programs that address food prices should be implemented and evaluated for their effects on fruit and vegetable consumption.

The relationship between hospital size and ICU type on select adverse patient outcomes.

The authors examined the relationships among hospital size and unit type, the prevalence of pressure ulcers, and rates of ventilator-associated pneumonia and catheter-related bloodstream infections in 25 intensive care units (ICUs) in 8 hospitals. Data came from the American Hospital Association survey, and nursing and infection control databases. Multiple regression was the main statistical technique. Pressure ulcer prevalence and catheter-related bloodstream infection rates were higher in large hospitals; ventilator-associated pneumonia rates were higher in surgical ICUs. Future researchers should include factors often hidden within hospital and unit characteristics to expose possible relationships that may be incorporated into interventions to prevent adverse outcomes.

Built Environment Exposures of Adults in the Moving to Opportunity Experiment.

This paper describes environmental exposures of adult participants in the Moving to Opportunity for Fair Housing (MTO) experiment over a four to seven year period from baseline to the interim evaluation. The MTO experiment randomized participants living in public housing or private assisted housing at baseline into experimental and control groups and provided a housing voucher for experimental group participants to move to neighborhoods with less than 10 percent of the population below the poverty line. However, few studies have examined how this move affected exposures to health promoting environments. We used data on residential locations of MTO participants and archival data on the built and food environment to construct environmental exposure variables. MTO participants in the experimental and Section 8 groups lived in neighborhoods with higher food prices, less high intensity development and more open space relative to the control group. The findings suggest that housing policies can have potential health consequences by altering health-related environmental exposures.

Intensive care units, communication between nurses and physicians, and patients' outcomes.

BACKGROUND: Various factors in hospitals can adversely affect patients' outcomes, including faulty communication between nurses and physicians. Whether specific communication elements (timeliness, accuracy, openness, understanding) can influence adverse outcomes is unknown. OBJECTIVES: To determine the relationships between patients' outcomes and (1) nurses' perceptions of elements of communication between nurses and physicians and (2) characteristics of the practice environment. METHODS: A cross-sectional survey design was used. Information on ventilator-associated pneumonia, bloodstream infection associated with a central catheter, and pressure ulcers was collected from 25 intensive care units in southeastern Michigan. Simultaneously, 462 nurses in those units (response rate, 53.3%) were anonymously surveyed. The Conditions for Work Effectiveness Questionnaire-II and the Practice Environment Scale of the Nursing Work Index were used to measure characteristics of the practice environment. The Intensive Care Unit Nurse-Physician Questionnaire was used to measure communication between nurses and physicians. Statistical tests included correlation and multiple regression. Analyses were conducted at the unit level. RESULTS: Unit response rates varied from 6% to 100%. Together, variability in understanding communication and capacity utilization were predictive of 27% of the variance in ventilator-associated pneumonia. Timeliness of communication was inversely related to pressure ulcers (r= -0.38; P=.06), and workplace empowerment and scores on the Acute Physiology and Chronic Health Evaluation III were positive predictors of ventilator-associated pneumonia (R(2)=0.36; P=.005). CONCLUSIONS: Not all elements of communication were related to the selected adverse outcomes. The connection between characteristics of the practice environment at the unit level and adverse outcomes remains elusive.

Reliability and validity of environmental audits using GigaPan® technology in parks.

Park quality and features can contribute to more engaging places for play and recreation. However, assessing park characteristics remains a challenge. This study measured the reliability of GigaPan® as a method for assessing park characteristics as well as the validity of GigaPan® compared to Google Street View (GSV) and direct observation (DO). A total of 65 target areas (16 parks total) in Pittsburgh, PA were assessed using GigaPan®, GSV, and DO from July 2015-January 2016. For reliability and validity, 14 and 28 variables were examined, respectively. Cohen's kappa was used to assess inter-rater reliability. Sensitivity and specificity were used to measure validity. Of the 14 variables included in the inter-rater reliability analysis, five variables had almost perfect reliability (kappa > 0.80) and three variables had substantial reliability (kappa > 0.60). Of the 28 variables included in the validity analysis, GigaPan® was able to correctly classify 17 of the 28 variables and GSV was able to correctly classify 15 of the 28 variables with a sensitivity >80%. There were no significant differences between sensitivity and specificity between GSV and GigaPan®. GigaPan® performed similarly to GSV with DO being used as the gold standard. Further, GigaPan overall had high reliability among the features measured. A strength of GigaPan® is the ability to be implemented quickly in the field, making it a viable alternative to GSV particularly when temporality is an important factor.

Impact of Rental Assistance on Modifiable Health Risk Factors and Behaviors in Adults.

OBJECTIVES: Housing may influence health through various mechanisms and is recognized as a social determinant of health. This study investigated the influence of rental assistance on modifiable health risk factors and behaviors using data from the Panel Study of Income Dynamics (PSID). Participants receiving rental assistance were compared with participants not receiving rental assistance on body mass index (BMI), obesity, smoking, alcohol use and physical activity. METHODS: Participants (N=1374) were age 18 to 62, head of household, and had not received rental assistance for four years prior to baseline. Treatment group participants (N=116) received rental assistance between baseline and the two-year follow-up. Comparison group participants (N=1258) were eligible for rental assistance two years after baseline but did not receive assistance. Models estimated the average treatment effect on treated (ATET) for each health indicator in each follow-up year. Participants were matched on age, race-ethnicity, gender, education, disability status, employment, household income and number of children in the household. RESULTS: At the two-year follow-up, smoking was significantly higher among treatment group participants. A sensitivity analysis excluding permanently disabled participants showed significantly higher obesity in the treatment group two years after baseline. No significant differences were found four or six years after baseline on any outcome. CONCLUSIONS: Rental assistance was associated with increased smoking and obesity two years after baseline, but did not influence BMI, alcohol consumption, or physical activity. Interventions to reduce smoking and obesity may improve the health of individuals who receive rental assistance.

Need for population specific validation of a portable metabolic testing system: a case of sedentary pregnant women.

Commercially available portable metabolic systems have been validated with samples of young, healthy, and well-fit subjects, but use of these systems with a special population, such as healthy but sedentary pregnant women, requires a unique set of considerations. These include a woman's limited testing time necessary for fetal safety, relatively low oxygen consumption, and the unique physiology of pregnancy (woman, the placenta, and the fetus). The purpose of this study was to validate a portable metabolic testing system (VO2000) with healthy sedentary pregnant women. A total of 9 sedentary pregnant women who averaged 30 years of age (SD=3), 93 kg (SD=19) weight, 163 cm (SD=7) height, and at 19 weeks' gestation (SD=5) volunteered to participate. Submaximum fitness tests using the Cornell protocol were conducted once with two systems (VO2000 and CPX/D, a reference) simultaneously, and then subsequently twice with one system (VO2000). The VO2000 consistently overestimated VO2 measurement, compared to the same manufacturer's reference system, by 4.4 +/- 3.6 (SD) ml/kg/min, and when VO2000 was used twice, the mean difference was statistically significant (1.0 +/- 1.8 [SD] ml/kg/min; t(45) = 3.9, p < .001). The results of the study show that although VO2000 is an established and validated portable metabolic system for measurement on adult males and females who are relatively well fit, this portable system consistently overestimates VO2 readings for pregnant women compared to standard full-size system. Measurements, when repeated, were not consistent.

Critical elements of documentation for data-based research.

Scientific integrity and progress are enhanced by precise documentation of the conceptual development and information management aspects of research. Careful and complete documentation of the research process supports accurate reporting. The exercise of documenting data management activities provides an opportunity for nurse researchers to reflect on a study to guide current work and inform and enhance future research. The literature includes many references to the need for data management but contains little advice regarding the nuts and bolts of documenting data management activities. This article describes specific steps for documenting data-based research beginning with the study design and ending with data analysis. The documentation framework and examples presented are sufficient to guide the comprehensive record keeping required for complex studies and can be modified to meet the simpler needs of smaller research projects.

Elder women's decision-making in breast cancer care: An Israeli study.

PURPOSE: Much research has examined women's decision-making behaviour in breast cancer care. Patient age has shaped preferences, values, decision style and participation in treatment decisions. The aim of this study was to test the validity of the Michigan Assessment of Decision Style (MADS) (Pierce, 1995) in an older cohort and provide information on decision styles to identify areas of tailored decision support necessary for Israeli women. METHODS: This study examined the decision-making styles of older Israeli women receiving routine mammography screening. Fifty two women over 65 years of age, attending a routine mammography screening, were administered a questionnaire containing demographic information and the MADS to determine hypothetical treatment decision-making. The MADS is a 16-item questionnaire assessing decision-making behaviour by characterizing four factors: avoiding, deferring, information-seeking and deliberation. RESULTS: Age, family history of breast cancer, and having a current mammography were not significantly associated with any of the four MADS factors. Deliberation and Deferring had the highest mean scores, followed closely by Information-Seeking and Avoidance. Correlations among the factors indicate a significant, positive correlation between Deliberation and Information-Seeking and a significant negative correlation between Deliberation and Deferring, consistent with previous studies. CONCLUSIONS: These findings indicate that older Israeli women's decision style is characterized by information seeking and deliberation reflecting a disposition towards engagement. The findings contribute to clinicians' understanding of women's preferences by countering the traditionally accepted stereotype that older women will employ a passive role when faced with an important health care decision.

The feasibility and utility of the aid to cardiac triage intervention to improve nurses' cardiac triage decisions.

BACKGROUND: Despite the benefits of prompt treatment of myocardial infarction, gender disparities exist in emergency department (ED) nurses' cardiac triage decisions. OBJECTIVE: To determine the feasibility and utility of the aid to cardiac triage (ACT) intervention designed to improve ED nurses' cardiac triage decisions for women with myocardial infarction. METHODS: A prospective, exploratory design was used. To determine feasibility, we evaluated the 1-hour time allocated for the intervention and ED nurses' participation rates. Twenty-three participants completed a utility questionnaire at the completion of the 1-hour intervention, and 18 participants completed the questionnaire 3 months post-intervention. RESULTS: The ACT intervention was delivered within 30 to 40 minutes, allowing 20 minutes for questions and discussion. ED nurses viewed the ACT intervention as a useful, helpful, and practical tool for improving their cardiac triage decisions at both intervention completion and 3 months later. CONCLUSION: The evaluation supports the feasibility and utility of the ACT intervention.

New parameters for daytime wandering.

This study aimed to describe wandering using new parameters and to evaluate parameters as a function of cognitive impairment and mobility. Forty-four wanderers in long-term care settings were videotaped 12 times. Rate and duration of wandering episodes were plotted and used to derive parameters from values above and below case medians, proportion of hours wandering, and time of day. Participants wandered during 47% of observations; on average, the hourly rate was 4.3 episodes, the peak hourly rate was 18 episodes, and the peak hourly duration was 19.9 minutes. Mini-Mental State Examination (MMSE) scores was negatively correlated with overall duration and number of observations during which duration exceeded 15 minutes per hour, was positively correlated with number of observations without wandering, and was not significantly correlated with rate-related parameters. Mobility correlated positively with rate and duration parameters. Interaction of MMSE score and mobility was the strongest predictor of wandering duration. Parameters derived from repeated measures provide a new view of daytime wandering and insight into relationships between MMSE score and mobility status with specific parameters of wandering.

A comparison of walking versus stretching exercises to reduce the incidence of preeclampsia: a randomized clinical trial.

OBJECTIVES: To compare a walking exercise to a stretching exercise during pregnancy in high-risk women who were sedentary and had previously experienced preeclampsia. METHODS: A randomized clinical trial of the effects of the two types of physical exercises was conducted between November 2001 and July 2006 in Washtenaw County, Michigan. Both groups engaged in the assigned exercise five times a week until the end of pregnancy. RESULTS: Women were randomized to either the walking group (n = 41) or the stretching group (n = 38). The walkers exercised an average of 36 (SD, 6) minutes at 18 weeks gestation, 34 (SD, 7) minutes at 28 weeks gestation, and 31 (SD, 12) minutes at the last week of the intervention. On average, they exercised within target heart rate ranges 35% (SD, 32%) at 18 weeks gestation, 22% (SD, 25%) at 28 weeks gestation, and 17% (SD, 25%) at the last week of the intervention. The stretching group engaged in stretching exercises following a 40-minutes videotape. On average, the walking group exercised 4 (SD, 1) times a week at 18 weeks gestation, 4 (SD, 1) time a week at 28 weeks gestation, and 3 (SD, 1) times a week at the last week of the intervention. Equally on average, the stretching group exercised 4 (SD, 2) times a week at 18 weeks gestation, 5 (SD, 1) times a week at 28 weeks gestation, and 3 (SD, 1) times a week at the last week of the intervention. No difference between groups was observed, but both exercised significantly less frequently over the time (p 0.0001). Together, participants reported average 7,040 (SD, 2,612) steps at the beginning and 5,711 (SD, 2,739) steps at the end of the study. The walkers tracked an average 8,501 (SE, 778) steps a day at 20 weeks gestation and 7,418 (SE, 788) steps at 34 weeks gestation (n.s.). The stretchers tracked an average 6,189 (SE, 704) steps at 20 weeks gestation and 4,848 (SE, 452) steps at 34 weeks gestation (p 0.05). The incidence of preeclampsia was 14.6% (95% CI, 5.6 to 29.2) among the walkers and 2.6% (95% CI; 0.07 to 13.8) among the stretchers. The incidence of gestational hypertension was 22 % (95% C.I., 8.7 to 35.2) for the walkers and 40% (95% CI, 23.2 to 55.8) for the stretchers. The mean transferrin level, an antioxidant marker, was significantly higher in the stretching group mean (412 mg/dL, 95%CI, 389 to 435) than the walkers at the time of labor (mean = 368 mg/dL, 95%CI, 346 to 391) (p 0.05). No significant group differences were observed in birth outcomes. CONCLUSION: Regular stretching exercises may promote endogenous antioxidants among women at risk for preeclampsia.