A pilot study evaluating online training for therapist delivery of interpersonal psychotherapy for eating disorders.

OBJECTIVE: Individuals with eating disorders (EDs) often do not receive evidence-based care, such as interpersonal psychotherapy (IPT), partly due to lack of accessible training in these treatments. The standard method of training (i.e., in-person workshops) is expensive and time consuming, prompting a need for more scalable training tools. The primary aim of this pilot and open trial was to examine the effects of an IPT online training platform on training outcomes (i.e., IPT fidelity, knowledge, and acceptance) and, secondarily, whether online training was different from in-person training (using a comparative sample from a separate study) in terms of training outcomes and patient symptoms. METHOD: Participants were therapists (N = 60) and student patients (N = 42) at 38 college counseling centers. Therapists completed baseline questionnaires and collected data from a student patient with ED symptoms. Therapists then participated in an IPT online training program and completed post-training assessments. RESULTS: Following online training, acceptance of evidence-based treatments, therapist knowledge of IPT, therapist acceptance of IPT, and treatment fidelity increased; acceptance of online training was high at baseline and remained stable after training. Using the 90% confidence interval on outcome effect sizes, results suggested IPT online training was not different from in-person training on most outcomes. Results are based on 60% of therapists who originally enrolled due to high dropout rate of therapist participants. CONCLUSIONS: Findings from this preliminary pilot study support the use of IPT online training, which could increase access to evidence-based ED treatment and improve patient care. PUBLIC SIGNIFICANCE: Lack of accessible therapist training has contributed to many therapists not delivering, and therefore many patients not receiving, evidence-based treatment. This study evaluated a highly disseminable online training and compared outcomes to traditional in-person training and found that training and patient outcomes were not different. Online training has the potential to enhance access to evidence-base care, which could in turn optimize patient outcomes.

Furthering development of the Eating Disorder Examination-Pregnancy Version (EDE-PV): Exploratory factor analysis and psychometric performance among a community sample of pregnant individuals with body mass index ≥ 25.

Psychometrically sound measures of disordered eating during pregnancy are needed, particularly for pregnant individuals with body mass index (BMI) ≥ 25, who are at high risk for disordered eating attitudes/behaviors. We previously adapted the Eating Disorder Examination (EDE) for use among pregnant individuals with BMI ≥ 25. This study examined the factor structure of the EDE-Pregnancy Version (EDE-PV) in a community sample of pregnant individuals with BMI ≥ 25. The EDE-PV was administered to 257 pregnant individuals with pre-pregnancy BMI ≥ 25 between 12 and 20 weeks gestation. The EDE-PV factor structure was determined using an exploratory factor analysis with oblique geomin rotation, internal consistency coefficients were calculated, and convergent and discriminant validity of the EDE-PV factors were assessed. An 11-item, two-factor solution produced an acceptable model fit. The subscales did not replicate those of the EDE and were interpreted as Pregnancy Eating and Weight Change Concerns and Pregnancy Shape and Weight Concerns (αs=.67 and .85; ωs=.70 and .85, respectively). These subscales showed small-to-moderate, positive correlations with weight and psychosocial distress measures and differentiated between participants with and without lifetime histories of any eating disorder diagnosis, demonstrating adequate convergent and discriminant validity. The results indicate that the EDE-PV can more reliably identify factors associated with disordered eating attitudes/behaviors among pregnant individuals with BMI ≥ 25 compared to the EDE and support our call for the development and use of new and/or adapted measures to appropriately assess disordered eating during pregnancy.

Trajectories of Return to Cigarette Smoking Up to 1 Year Postpartum Among People Who Quit Smoking During Pregnancy.

INTRODUCTION: Previous work has identified predictors of relapse to smoking postpartum among parenting people who quit during pregnancy, but less is known about the time course of postpartum relapse. The study goals were to document patterns and correlates of smoking resumption among people who quit smoking during pregnancy and were motivated to remain abstinent. AIMS AND METHODS: We conducted a secondary analysis among participants in a randomized controlled trial of postpartum-specific smoking relapse prevention interventions who self-reported no smoking since the quit date to delivery (n = 280). Participants provided expired air samples of carbon monoxide, and completed self-report measures of mood, perceived stress, and demographic and pregnancy-related information. Timeline follow-back interviews were conducted at the end of pregnancy and 12-, 24-, and 52-weeks postpartum. RESULTS: The largest group (49.7% of participants) belonged to a trajectory reflecting abstinence across 1 year postpartum. Another 13% remained abstinent 5-6 months after delivery. However, one in five started to smoke consistently within 100 days after delivery, and 16% relapsed in a pattern that can be described as inconsistent smoking. Participants with more prior quit attempts and those who smoked more cigarettes prior to their quit attempt were more likely to relapse within 100 days of delivery. CONCLUSIONS: The first 3 months postpartum represent a critical window for relapse prevention, given that most individuals who relapsed did so in the first 100 days or so after delivery. Assessing prior smoking history can help identify pregnant people who will need additional support in the early postpartum period. IMPLICATIONS: Relapse to smoking during the year after childbirth is common, but the time course of relapse after delivery is poorly understood. This study provides evidence for 4 distinct trajectories of relapse, and highlights variables linked to early relapse that may improve efforts to target and time intervention efforts. Specifically, assessing age at initiation, quantity of tobacco use prior to quit attempt, and number of previous quit attempts will identify pregnant people at greatest risk of early relapse. These findings also suggest that additional support early in the postpartum period is crucial for most people in the postpartum who will relapse.

Documenting the course of loss of control over eating prior to, during and after pregnancy among women with pre-pregnancy overweight and obesity.

OBJECTIVE: Loss of control over eating (LOC) is common among women, particularly those with overweight and obesity (OV/OB), and predicts weight gain. Given the importance of understanding weight and eating behaviors during pregnancy, we sought to characterize LOC across pregnancy and the postpartum period among women with pre-pregnancy OV/OB. METHODS: Pregnant women (N = 257; 28.44 ± 5.48 years old) with self-reported OV/OB prior to pregnancy were interviewed using a pregnancy-adapted version of the Eating Disorder Examination (EDE-PV). Pre-pregnancy LOC was retrospectively assessed during the first trimester and then prospectively assessed monthly throughout pregnancy and postpartum over the course of seven assessments. RESULTS: Rates of LOC were significantly higher during pregnancy compared to prior to ( χ12 =44.845, p < .01) and after ( χ12 =36.379, p < .01) pregnancy, with 37% (n = 95) of women reporting ≥1 LOC episode during pregnancy. LOC during pregnancy was associated with higher likelihood of LOC postpartum. Higher age (OR = 1.084, p = .04) and identifying as a minority (OR = 0.344, p = .02) was associated with greater likelihood of experiencing LOC during pregnancy only. DISCUSSION: LOC during pregnancy is common among women with pre-pregnancy OV/OB, suggesting that screening and intervention for LOC during pregnancy may be warranted. Future research is necessary to examine the relationship between LOC during pregnancy and maternal and infant health outcomes.

Depressive Symptoms Assessed Near the End of Pregnancy Predict Differential Response to Postpartum Smoking Relapse Prevention Intervention.

BACKGROUND: Depressive symptoms are prevalent during pregnancy and the postpartum period and affect risk for smoking relapse. Whether and how depression affects response to postpartum interventions designed to sustain smoking abstinence is unknown. PURPOSE: We examined end-of-pregnancy depressive symptoms as a moderator of response to two postpartum-adapted smoking relapse prevention interventions. METHODS: Women (N = 300) who quit smoking during pregnancy were randomized to receive either a postpartum intervention focused on psychosocial factors linked to postpartum smoking (Strategies to Avoid Returning to Smoking [STARTS]) or an attention-controlled comparison intervention (SUPPORT). Women completed the Edinburgh Postnatal Depression Scale at the end of pregnancy. Smoking status was biochemically assessed at the end of pregnancy and at 12, 24, and 52 weeks postpartum. RESULTS: End-of-pregnancy depressive symptoms moderated response to postpartum smoking relapse prevention interventions (χ2 = 10.18, p = .001). After controlling for variables previously linked to postpartum smoking relapse, women with clinically significant end-of-pregnancy depressive symptoms (20%) were more likely to sustain abstinence through 52 weeks postpartum if they received STARTS. In contrast, women with few end-of-pregnancy depressive symptoms were more likely to sustain abstinence through 52 weeks postpartum if they received SUPPORT. Changes in the psychosocial factors addressed in the STARTS intervention did not mediate this moderation effect. CONCLUSION: Assessment of end-of-pregnancy depressive symptoms may help determine success following postpartum smoking relapse prevention interventions. Women with elevated end-of-pregnancy depressive symptoms benefited from postpartum relapse prevention intervention tailored to their psychosocial needs, while those with few symptoms were more successful in postpartum intervention that used standard behavioral components. CLINICAL TRIAL REGISTRATION: NCT00757068.

Improvements in Maternal Cardiovascular Health Over the Perinatal Period Longitudinally Predict Lower Postpartum Psychological Distress Among Individuals Who Began Their Pregnancies With Overweight or Obesity.

BACKGROUND: Adverse cardiovascular events during pregnancy (eg, preeclampsia) occur at higher rates among individuals with overweight or obesity (body mass index ≥25 kg/m2) and have been associated with postpartum depression. The present study examined whether changes in cardiovascular health (CVH) during the perinatal period, as defined by the American Heart Association's Life's Essential 8 framework, predicted postpartum psychological functioning among individuals with prepregnancy body mass index ≥25 kg/m2. METHODS AND RESULTS: Pregnant individuals (N = 226; mean ± SD age = 28.43 ± 5.4 years; mean body mass index = 34.17 ± 7.15 kg/m2) were recruited at 12 to 20 weeks of gestation (mean, 15.64 ± 2.45 weeks) for a longitudinal study of health and well-being. Participants completed ratings of depression and perceived stress and reported on CVH behaviors (dietary intake, physical activity, nicotine exposure, and sleep) at baseline and at 6 months postpartum. Body mass index and CVH behaviors were used to calculate a composite CVH score at both time points. Linear regression analyses were performed to examine whether change in CVH related to postpartum symptom scores. Because sleep was measured in only a subset of participants (n = 114), analyses were conducted with and without sleep. Improved CVH was associated with lower postpartum depression (ß = -0.18, P<0.01) and perceived stress (ß = -0.13, P=0.02) scores. However, when including sleep, these relationships were no longer significant (all P>0.4). CONCLUSIONS: Improvements in CVH from early pregnancy to 6 months postpartum were associated with lower postpartum depressive symptoms and perceived stress but not when including sleep in the CVH metric, potentially due to the large reduction in sample size. These data suggest that intervening during pregnancy to promote CVH may improve postpartum psychological functioning among high-risk individuals.

Change in parent and child psychopathology following obesity treatment and maintenance: A secondary data analysis.

BACKGROUND: General and eating disorder (ED) psychopathology are common among children and adults with overweight/obesity; few studies have examined their course of change throughout family-based behavioural obesity treatment (FBT) and maintenance. OBJECTIVES: Examine: (1) the changes in the parent and child general and ED psychopathology during FBT and maintenance interventions; (2) the associations between change in psychopathology and change in weight among children or parents; (3) the associations between change in psychopathology within parent-child dyads. METHODS: 172 parent-child dyads participated in 4-month FBT and were subsequently randomized to one of three 8-month maintenance interventions. General psychopathology (child anxiety/depressive symptoms, parent severity of global psychological distress), ED psychopathology (shape/weight concern), and percent overweight were assessed at baseline, post-FBT, and post-maintenance. Separate linear mixed-effects models evaluated change in general and ED psychopathology, including an interaction between maintenance condition and time. Partial correlations examined associations between change in psychopathology and percent overweight among children or parents, and associations between change in psychopathology within parent-child dyads. RESULTS: Among children, significant reductions were observed from baseline to post-FBT in all forms of psychopathology and from post-FBT to post-maintenance in general psychopathology. Among parents, significant reductions were observed from baseline to post-FBT in all forms of psychopathology; reductions were maintained from post-FBT to post-maintenance. There was no significant interaction between maintenance condition and time. Correlations between change in most forms of parent or child psychopathology and percent overweight were observed. CONCLUSIONS: Participation in FBT and maintenance was associated with improvements in general and ED psychopathology in both parents and children.

Examining the interdependence of parent-child dyads: Effects on weight loss and maintenance.

BACKGROUND: This study aimed to further elucidate correlated weight changes in parent-child dyads enrolled in family-based treatment (FBT) by modeling the interdependence of weight changes during treatment. METHODS: Parent-child dyads (n = 172) with overweight/obesity (child mean zBMI = 2.16 ± 0.39; parent mean BMI = 37.9 ± 9.4 kg/m2 ) completed 4 months of FBT and were randomized to one of three 8-month maintenance interventions (Social Facilitation Maintenance [SFM]-high dose, SFM-low dose or control). Weight/height was measured at 0, 4 and 12 months. Structural equation models simultaneously estimated the effect that an individual had on their own (actor effect) and on one another's (partner effect) weight-status across time using the actor-partner interdependence model. RESULTS: Actor paths were significant over time for parent and child. Partner paths were significant for child zBMI predicting parent BMI at 4 and 12 months. Maintenance condition moderated actor/partner paths in the model. CONCLUSIONS: Child weight change may motivate parents to make environmental and behavioural changes that impact their own weight. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00759746.

Correlates of Physical Activity Engagement among Pregnant Women with Overweight and Obesity.

BACKGROUND: Excess weight during pregnancy increases risk for adverse obstetrical outcomes. Physical activity (PA) may buffer these effects, although it is unclear what factors are associated with PA in women who begin pregnancy with overweight/obesity. The present study sought to characterize the demographic and psychological correlates of PA among women with prepregnancy overweight/obesity. METHODS: Pregnant women (N = 249; mean age, 28.48 ± 5.48 years; mean body mass index, 34.13 ± 7.07 kg/m2) at 12-20 weeks of gestation (mean, 15.68 ± 2.44 weeks of gestation) completed ratings of perceived stress and depressive symptoms and were interviewed using the pregnancy version of the Eating Disorders Examination. The Paffenbarger Physical Activity Survey was administered via interview to estimate energy expenditure. Continuous outcomes were evaluated via linear regression, while logistic regression was conducted to assess likelihood of meeting PA guidelines. RESULTS: Mean weekly duration of moderate to vigorous PA was 109.50 ± 248.17 minutes, with 21% of women meeting federal PA guidelines of 150 minutes or more. Higher perceived stress (ß = -0.217; p = .02) and eating psychopathology (ß = -0.213; p < .01) were associated with lower total energy expenditure. Black women reported lower expenditure specifically from walking compared with White women (ß = -0.180; p = .03). Depressive symptoms were not associated with PA. No estimate of PA predicted body mass index. CONCLUSIONS: Pregnant women with overweight/obesity engage in modest amounts of PA early in pregnancy, although few meet PA guidelines. Greater perceived stress and eating psychopathology were associated with lower PA engagement. These factors should be monitored by obstetrics providers to identify women who may particularly benefit from counseling about PA during pregnancy.

Trial design and methodology for a non-restricted sequential multiple assignment randomized trial to evaluate combinations of perinatal interventions to optimize women's health.

Pre-pregnancy overweight/obesity and excessive gestational weight gain (GWG) independently predict negative maternal and child health outcomes. To date, however, interventions that target GWG have not produced lasting improvements in maternal weight or health at 12-months postpartum. Given that interventions solely aimed at addressing GWG may not equip women with the skills needed for postpartum weight management, interventions that address health behaviors over the perinatal period might maximize maternal health in the first postpartum year. Thus, the current study leveraged a sequential multiple assignment randomized trial (SMART) design to evaluate sequences of prenatal (i.e., during pregnancy) and postpartum lifestyle interventions that optimize maternal weight, cardiometabolic health, and psychosocial outcomes at 12-months postpartum. Pregnant women (N = 300; ≤16 weeks pregnant) with overweight/obesity (BMI ≥ 25 kg/m2) are being recruited. Women are randomized to intervention or treatment as usual on two occasions: (1) early in pregnancy, and (2) prior to delivery, resulting in four intervention sequences. Intervention during pregnancy is designed to moderate GWG and introduce skills for management of weight as a chronic condition, while intervention in the postpartum period addresses weight loss. The primary outcome is weight at 12-months postpartum and secondary outcomes include variables of cardiometabolic health and psychosocial well-being. Analyses will evaluate the combination of prenatal and postpartum lifestyle interventions that optimizes maternal weight and secondary outcomes at 12-months postpartum. Optimizing the sequence of behavioral interventions to address specific needs during pregnancy and the first postpartum year can maximize intervention potency and mitigate longer-term cardiometabolic health risks for women.