Understanding problematic eating in out-of-home care: The role of attachment and emotion regulation.

Children living in Out-of-Home Care (OoHC) are thought to be especially vulnerable to developing problematic eating behaviours due to their likelihood of having insecure attachment styles and emotion regulation deficits. Despite this increased risk, our understanding of problematic eating among children in OoHC is limited. Therefore, this study aimed to; (1) Explore the rate of problematic eating behaviours among children living in OoHC, specifically residential and foster care; (2) Investigate how carers manage problematic eating and (3) Understand carers' perceptions of the role of attachment and emotion regulation in relation to problematic eating in OoHC. Semi-structured interviews, focus groups, and surveys were conducted with residential care staff (n = 36) and foster carers (n = 8) in Victoria, Australia. Interviews were recorded, transcribed, and analysed for themes, and frequency data from the survey were generated. Residential and foster carers reported that approximately 38% of the children in their care displayed problematic eating behaviours at a clinical level. Both residential and foster carers commonly understood these behaviours as a function of the child's experiences of food deprivation and limited access to healthy foods prior to entering care which, they believe, has contributed to problems with regulating food intake and/or willingness to try new foods. Carers also commonly reported that the children in their care struggle to form attachments or regulate their emotions, which impacts carers ability to manage problematic eating. It is recommended that future interventions prioritise educating community service organisations (CSOs), responsible for delivering OoHC, to better recognise and address problematic eating behaviours. This will enable CSOs to train their residential and foster carers about how best to respond to and manage problematic eating behaviours.

A systematic review of the psychosocial correlates of intuitive eating among adult women.

Intuitive eating has been proposed as an eating style that fosters a positive attitude towards food, the body, and physical activity. A systematic review of the literature was undertaken to examine intuitive eating in relation to disordered eating, body image, emotional functioning, and other psychosocial correlates in adult women. Articles were identified through Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source (Nursing and Academic Edition), Medline Complete, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, PubMed and Scopus. Eligible studies were those that examined women aged 18 years and older, measured intuitive eating, and assessed a psychosocial correlate of intuitive eating. Twenty-four cross-sectional studies, published between 2006 and September 2015, met eligibility criteria. Intuitive eating was associated with less disordered eating, a more positive body image, greater emotional functioning, and a number of other psychosocial correlates that have been examined less extensively. However, given that all studies used cross-sectional designs, no conclusions regarding the direction of the relationship between intuitive eating and psychosocial correlates can be drawn. Participants in the majority of studies were university students in the United States so findings cannot be generalised to the wider population of female adults. Prospective studies are now needed to verify these cross-sectional findings, and show if intuitive eating may reduce disordered eating and body image concerns, and promote women's psychological health and well-being.

Repair of a Crossbow Bolt Injury of the Subclavian Artery Behind the Mid-clavicle.

The management of a rare midclavicular crossbow bolt injury to the subclavian artery is discussed. Important concepts include the initial clinical diagnosis, operative planning, the surgical approach to the retro-clavicular great vessels, the technical aspects of repair, and postoperative course. A discussion of the reasoning behind an operative vs. endovascular approach is also discussed.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy.

Importance: There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments. Objective: To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy. Design, Setting, and Participants: For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020. Exposure: Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy. Main Outcomes and Measures: Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders. Results: A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses. Conclusions and Relevance: In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

Protocol for a randomized controlled trial of a specialized health coaching intervention to prevent excessive gestational weight gain and postpartum weight retention in women: the HIPP study.

BACKGROUND: Pregnancy is a time of significant physiological and physical change for women. In particular, it is a time at which many women are at risk of gaining excessive weight. We describe the rationale and methods of the Health in Pregnancy and Post-birth (HIPP) Study, a study which aims primarily to determine the effectiveness of a specialized health coaching (HC) intervention during pregnancy, compared to education alone, in preventing excessive gestational weight gain and postpartum weight retention 12 months post birth. A secondary aim of this study is to evaluate the mechanisms by which our HC intervention impacts on weight management both during pregnancy and post birth. METHODS/DESIGN: The randomized controlled trial will be conducted with 220 women who have a BMI > 18.5 (American IOM cut-off for normal weight), are 18 years of age or older, English speaking, no history of disordered eating or diabetes and are less than 18 weeks gestation at recruitment. Women will be randomly allocated to either a specialized HC intervention group or an Education Alone group. Our specialized HC intervention has two components: (1) one-on-one sessions with a Health Coach, and (2) two by two hour educational group sessions led by a Health Coach. Women in the Education Alone group will receive two by two hour educational group sessions with no HC components. Body Mass Index, waist circumference, and psychological factors including motivation, readiness to change, symptoms of depression and anxiety, and body dissatisfaction will be assessed at baseline (14-16 weeks gestation), and again at follow-up: 32 weeks gestation, 6 weeks, 6 months and 12 months postpartum. DISCUSSION: Our study responds to the urgent need to design effective interventions in pregnancy to prevent excessive gestational weight gain and postpartum weight retention. Our pregnancy HC intervention is novel and innovative and has been designed to be easily adopted by health professionals who work with pregnant women, such as obstetricians, midwives, allied health professionals and health psychologists. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000331932.

Implementing a healthy lifestyle program in residential out-of-home care: What matters, what works and what translates?

The Healthy Eating, Active Living Matters (HEALing Matters) program is being scaled up across residential out-of-home care (OOHC) in Victoria, Australia and is providing young people with the knowledge, skills and resources to promote better health through healthy eating and activity. HEALing Matters was piloted as the HEAL program, a dual-intervention program that aimed to provide young people living in residential care with education and opportunities to improve their eating and physical activity habits, while simultaneously building the capacity of their carers to promote, encourage and role model healthy lifestyle behaviours. Qualitative findings indicated that HEAL resulted in increased participation in community sport, increased availability of sports equipment, healthy meal preparation and healthy food availability and improvements in perceived young person self-esteem and independent living skills. Findings also revealed some limitations of the program. Following the pilot, a participatory methodological approach was used to better understand how to align the HEAL program with individual and community needs. This approach engaged diverse stakeholders to better understand the barriers and enablers, address limitations, identify key intervention points and build trust and a shared vision to co-design the HEALing Matters program. HEALing Matters is now delivered within a framework that is informed by attachment, trauma and resilience theories. This paper outlines the HEALing Matters journey from what matters, to what works, to what translates in relation to a healthy eating and active living intervention in OOHC.

Continuity of midwifery care and gestational weight gain in obese women: a randomised controlled trial.

BACKGROUND: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women's experience of pregnancy care; women's satisfaction with care and a range of psychological factors. METHODS/DESIGN: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI ≥ 30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include socio-demographic information and the use of validated scales to measure secondary outcomes. DISCUSSION: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610001078044.

Factors associated with breastfeeding to 3 months postpartum among women with type 1 and type 2 diabetes mellitus: An exploratory study.

PROBLEM: Breastfeeding has significant health benefits for maternal and infant health, yet women with pre-pregnancy diabetes (type 1 or type 2 diabetes mellitus) are often less likely to breastfeed compared with other childbearing women. BACKGROUND: Intention to breastfeed and making the decision to breastfeed during pregnancy are significant predictors of breastfeeding in the general population, but intention to breastfeed has not been assessed during pregnancy among women with pre-pregnancy diabetes. AIM: To investigate factors associated with breastfeeding to three months postpartum, including demographic, health and reproductive characteristics, perceived support and pre-birth intention to breastfeed, among women with pre-pregnancy diabetes. METHODS: A prospective cohort of women with pre-pregnancy diabetes was recruited at three metropolitan hospitals in Melbourne, Australia. Women completed surveys during the third trimester of pregnancy (including intention to breastfeed) and at approximately 3 months postpartum (including current breastfeeding). Factors associated with any breastfeeding at 3 months postpartum were investigated using logistic regression. FINDINGS: Pregnancy surveys were completed by 79 women; three-month postpartum data were available for 47 women. Of these, more than two-thirds (n=32, 68%) indicated that they were breastfeeding. Controlling for other relevant variables, only pre-birth intention to breastfeed was significantly associated with any breastfeeding at three months (Adjusted Odds Ratio (95% confidence intervals, p)=20.49 (20.18-20.80, 0.017)). DISCUSSION: Pre-birth intention to breastfeed was the only significant predictor of continued breastfeeding to 3 months postpartum. CONCLUSION: Pregnancy provides an important opportunity for health professionals to educate and support women with pre-pregnancy diabetes about their breastfeeding intentions.

Psychosocial wellbeing among new mothers with diabetes: Exploratory analysis of the postnatal wellbeing in transition questionnaire.

OBJECTIVE: The Postnatal Wellbeing in Transition (PostTrans) Questionnaire assesses psychosocial wellbeing among women transitioning to motherhood while managing pre-existing diabetes. Face and content validity have been previously reported; however the PostTrans questionnaire has 51 items which imposes a substantial burden on respondents. The aim of this study was exploratory analysis of the PostTrans questionnaire to investigate whether a reduction in the number of items was statistically supported, and whether clinically meaningful subscales could be derived. METHODS: A prospective cohort of women with type 1 or type 2 diabetes was recruited from three metropolitan hospitals in Melbourne, Australia. Women completed surveys across three postnatal time points. Data were pooled for the analysis. Suitability for factor analysis was confirmed and exploratory Principal Components Analysis with oblique rotation was conducted. RESULTS: The number of responses in the pooled dataset was 117. The reduced PostTrans scale has 27 items and six factors, which together explain 68.7% of the variance. The subscales assess: feeling as if one is coping with diabetes and the infant; feeling anxious and guilty about diabetes; feeling supported by family; sensitivity to the opinions of others; prioritising self-care; and health professional support. CONCLUSION: The number of items in the PostTrans Questionnaire was reduced from 51 to 27 items. Six meaningful subscales emerged, which can help health professionals identify and address areas in which women with diabetes are experiencing psychosocial difficulties. The revised scale provides a feasible instrument to be tested for psychometric properties in a larger sample.

Lifestyle and Psychological Factors Associated with Pregnancy Intentions: Findings from a Longitudinal Cohort Study of Australian Women.

BACKGROUND: Preconception is a critical time for the establishment of healthy lifestyle behaviours and psychological well-being to reduce adverse maternal and offspring outcomes. This study aimed to explore relationships between preconception lifestyle and psychological factors and prospectively assessed short- (currently trying to conceive) and long-term (future parenthood aspirations) pregnancy intentions. METHODS: Data from Wave 3 (age 25-30 years; n = 7656) and Wave 5 (age 31-36 years; n = 4735) from the Australian Longitudinal Study of Women's Health were used. Pregnancy intentions and parenthood aspirations were evaluated. Logistic regressions explored cross-sectional associations between demographic, lifestyle and psychological factors and pregnancy intentions/parenthood aspirations. RESULTS: In multivariable models, parity and marital status were associated consistently with pregnancy intentions and parenthood aspirations. Few lifestyle behaviours and no psychological factors were associated with pregnancy intentions. Alcohol intake was the only behaviour associated with aspirations to have a first child. Aspirations for a second/subsequent child were associated negatively with physical activity, sitting time, diet quality, lower anxiety and higher stress. CONCLUSIONS: It appears that women are not changing their behaviours when they form a decision to try to conceive. Interventions are needed that address women's preconception needs, to optimise lifestyle and improve health outcomes for women and their families.

A systematic mapping review of the associations between pregnancy intentions and health-related lifestyle behaviours or psychological wellbeing.

The aim of this study was to conduct a systematic mapping review of the literature that explored associations of pregnancy intentions with health-related lifestyle behaviours and psychological wellbeing before and during pregnancy. Six databases were searched (May 2017) for papers relating to pregnancy intentions, health-related lifestyle behaviours, and psychological wellbeing. The literature was mapped according to the preconception or pregnancy period; prospective or retrospective variable assessment; and reported lifestyle behaviours and psychological wellbeing outcomes. Of 19,430 retrieved records, 303 studies were eligible. Pregnancy intentions were considered during the preconception period in 103 studies (only 23 assessed prospectively), and during the pregnancy period in 208 studies (141 prospectively). Associations between pregnancy intention and preconception behaviours/psychological wellbeing were primarily reported for supplement use (n = 58) and were lacking for diet/exercise, and psychological factors. For behaviours/psychological wellbeing during pregnancy, associations with pregnancy intention were focused on prenatal care (n = 79), depression (n = 61), and smoking (n = 56) and were lacking for diet/exercise. Only 7 studies assessed pregnancy intentions with a validated tool. Despite a large body of literature, there were several methodological limitations identified, namely assessment of pregnancy intentions with non-validated measures and the reliance on retrospective assessment. Future primary studies are needed to fill gaps in our understanding regarding energy-balance-related behaviours. Future studies (including reviews/meta-analyses) should take care to address the noted limitations to provide a comprehensive and accurate understanding of the relationships between pregnancy intentions and health-related lifestyle behaviours and psychological wellbeing before and during pregnancy.

Student midwives' intention to deliver weight management interventions: A theory of planned behaviour & self-determination theory approach.

OBJECTIVES: Overweight and obesity during pregnancy is a risk to the health of mother and child. Midwives can modify this key risk factor by providing weight management interventions to women before and during pregnancy. This study investigated social cognitive determinants of pre-clinical student midwives' intention to provide weight management intervention in preconception and antenatal clinical contexts. Social cognitive determinants from the theory of planned behaviour (attitudes, subjective norms, perceived behavioural control) and self-determination theory (autonomous motivation) were used to predict pre-clinical students' intentions once they enter practice. METHOD: The sample was 183 female pre-clinical student midwives from 17 Australian universities (age range = 18-54 years). Participants received a cross-sectional questionnaire that measured demographic items, attitudes, subjective norms, perceived behavioural control and autonomous motivation towards providing weight management intervention at two different stages of pregnancy - preconception and antenatal. RESULTS: Attitudes, subjective norms, and perceived behavioural control accounted for 56% of intention to provide weight management interventions to women planning pregnancy; however, the addition of autonomous motivation was non-significant. In contrast, attitudes and subjective norms (but not perceived behavioural control) accounted for 39% of intention to provide weight management interventions to women during pregnancy. Furthermore, the addition of autonomous motivation to the model was significant and accounted for an additional 3.1% of variance being explained. IMPLICATIONS AND CONCLUSIONS: Curriculum changes that support and increase pre-clinical student midwives' intention should focus on these specific correlates of intention in order to foster long term changes in clinical practice. Changes to the education and training of midwives should be carefully considered to understand their impact on these important determinants of intention to engage in this critical clinical skill.

Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries: A Systematic Review Update.

BACKGROUND: Worldwide, women seldom reach the recommended target of exclusive breastfeeding up to 6 months postpartum. The aim of the current study was to update a previously published review that presented a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding up to 6 months in high-income countries. MATERIALS AND METHODS: A systematic search of leading databases was conducted for scholarly, peer-reviewed, randomized controlled trials published from June 2013 to December 2016. Twelve new articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence in regard to duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach. RESULTS: A significant increase in the duration of exclusive breastfeeding was found in 4 of the 12 studies. All four successful interventions had long-duration postpartum programs, implemented by telephone, text message, or through a website. Some of the successful interventions also included prenatal education or in-hospital breastfeeding support. CONCLUSIONS: Results from this review update correspond closely with previous findings, in that all of the successful interventions had lengthy postnatal support or an education component. More studies assessed intervention fidelity than in the previous review; however, there was little discussion of maternal body-mass index. While a pattern of successful interventions is beginning to emerge, further research is needed to provide a robust evidence base to inform future interventions, particularly with overweight and obese women.

Health coaching to prevent excessive gestational weight gain: A randomized-controlled trial.

OBJECTIVES: The objectives of this study were to evaluate the efficacy of a health coaching (HC) intervention designed to prevent excessive gestational weight gain (GWG), and promote positive psychosocial and motivational outcomes in comparison with an Education Alone (EA) group. DESIGN: Randomized-controlled trial. METHODS: Two hundred and sixty-one women who were <18 weeks pregnant consented to take part. Those allocated to the HC group received a tailored HC intervention delivered by a Health Coach, whilst those in the EA group attended two education sessions. Women completed measures, including motivation, psychosocial variables, sleep quality, and knowledge, beliefs and expectations concerning GWG, at 15 weeks of gestation (Time 1) and 33 weeks of gestation (Time 2). Post-birth data were also collected at 2 months post-partum (Time 3). RESULTS: There was no intervention effect in relation to weight gained during pregnancy, rate of excessive GWG or birth outcomes. The only differences between HC and EA women were higher readiness (b = 0.29, 95% CIs = 0.03-0.55, p < .05) and the importance to achieve a healthy GWG (b = 0.27, 95% CIs = 0.02-0.52, p < .05), improved sleep quality (b = -0.22, 95% CIs = -0.44 to -0.03, p < .05), and increased knowledge for an appropriate amount of GWG that would be best for their baby's health (b = -1.75, 95% CI = -3.26 to -0.24, p < .05) reported by the HC at Time 2. CONCLUSIONS: Whilst the HC intervention was not successful in preventing excessive GWG, several implications for the design of future GWG interventions were identified, including the burden of the intervention commitment and the use of weight monitoring. STATEMENT OF CONTRIBUTION: What is already known on the subject? Designing interventions to address gestational weight gain (GWG) continues to be a challenge. To date, health behaviour change factors have not been the focus of GWG interventions. What does this study add? Our health coaching (HC) intervention did not reduce GWG more so than education alone (EA). There was an intervention effect on readiness and importance to achieve healthy GWG. Yet there were no group differences regarding confidence to achieve healthy GWG post-intervention.

The association between ante- and postnatal depressive symptoms and obesity in both mother and child: a systematic review of the literature.

AIM: The aim of this paper was to review the literature reporting on the relationship between ante- and postnatal maternal depressive symptoms and both maternal and childhood obesity. METHOD: Articles were sourced from Medline, PsychInfo, Health Source: Nursing/Academic Edition, Academic Search Premiere, and CINAHL. The search was limited to English papers published between January 2000 and June 2011 with key search terms including a combination of maternal, ante- and postnatal depression, obesity, and child. After screening, this resulted in 14 articles, 9 that addressed maternal depressive symptoms and maternal obesity and 5 that focused on maternal depressive symptoms and childhood obesity. GRADE guidelines were used to assess the quality of evidence on two outcomes: Maternal overweight/obesity (body mass index [BMI]) and childhood overweight/obesity (BMI). RESULTS: Nine studies examined the association between postnatal depressive symptoms and maternal obesity; three were cross-sectional and six were longitudinal. None of the cross-sectional studies that examined the association between postnatal depressive symptoms and maternal obesity (BMI) reported a significant positive association. In contrast, of the six studies that used a longitudinal design, three found an association between depressive symptoms and maternal BMI. Five studies were found examining ante- and postnatal depressive symptoms and childhood obesity, four longitudinal and one cross-sectional. Three found a positive association-the cross-sectional study and two longitudinal studies. The quality of the evidence for the two outcomes-maternal and childhood obesity-was low. CONCLUSION: Research addressing perinatal maternal depressive symptoms and maternal obesity, as well as research addressing perinatal maternal depressive symptoms and childhood obesity, is limited, is of low quality as a body of evidence, and thus far findings have been inconclusive. Further longitudinal and prospective research, incorporating objective measures of BMI and validated measures of depression, is warranted.