Diet Quality in a Weight Gain Prevention Trial of Reproductive Aged Women: A Secondary Analysis of a Cluster Randomized Controlled Trial.

Reproductive-aged women are at high risk for obesity development. Limited research exploring weight gain prevention initiatives and associated modifiable risk factors, including diet quality exists. In a secondary analysis of a 12 month, cluster randomized controlled trial for weight gain prevention in reproductive-aged women, we evaluated change in diet quality, macronutrient and micronutrient intake, predictors of change and associations with weight change at follow-up. Forty-one rural towns in Victoria, Australia were randomized to a healthy lifestyle intervention (n = 21) or control (n = 20). Women aged 18⁻50, of any body mass index and without conditions known to affect weight, were recruited. Diet quality was assessed by the Dietary Guideline Index (DGI) and energy, macronutrient, and micronutrient intake as well as anthropometrics (weight; kg) were measured at baseline and 12 months. Results were adjusted for group (intervention/control), town cluster, and baseline values of interest. Of 409 women with matched data at baseline and follow-up, 220 women were included for final analysis after accounting for plausible energy intake. At 12 months, diet quality had improved by 6.2% following the intervention, compared to no change observed in the controls (p < 0.001). Significant association was found between a change in weight and a change in diet quality score over time ß -0.66 (95%CI -1.2, -0.12) p = 0.02. The percentage of energy from protein (%) 0.009 (95%CI 0.002, 0.15) p = 0.01 and glycemic index -1.2 (95%CI -2.1, -0.24) p = 0.02 were also improved following the intervention, compared to the control group. Overall, a low-intensity lifestyle intervention effectively improves diet quality, with associated weight gain preventions, in women of reproductive age.

Exploring Diet Quality between Urban and Rural Dwelling Women of Reproductive Age.

Health disparities, including weight gain and obesity exist between urban and rural dwelling women. The primary aim was to compare diet quality in urban and rural women of reproductive age, and secondary analyses of the difference in macronutrient and micronutrient intake in urban and rural women, and the predictors of diet quality. Diet quality was assessed in urban (n = 149) and rural (n = 394) women by a modified version of the Dietary Guideline Index (DGI) energy, macronutrient and micronutrient intake from a food frequency questionnaire (FFQ) and predictors of diet quality. Diet quality did not significantly differ between urban and rural women (mean ± standard deviation (SD), 84.8 ± 15.9 vs. 83.9 ± 16.5, p = 0.264). Rural women reported a significantly higher intake of protein, fat, saturated fat, monounsaturated fat, cholesterol and iron and a higher score in the meat and meat alternatives component of the diet quality tool in comparison to urban women. In all women, a higher diet quality was associated with higher annual household income (>$Australian dollar (AUD) 80,000 vs. <$AUD80,000 p = 0.013) and working status (working fulltime/part-time vs. unemployed p = 0.043). Total diet quality did not differ in urban and rural women; however, a higher macronutrient consumption pattern was potentially related to a higher lean meat intake in rural women. Women who are unemployed and on a lower income are an important target group for future dietary interventions aiming to improve diet quality.

Individual, social and environmental factors and their association with weight in rural-dwelling women.

OBJECTIVE: Obesity is a major public health concern and women living in rural settings present a high-risk group. With contributing factors poorly explored, we evaluated their association with weight in rural Australian women. METHODS: Women aged 18-50 years of any body mass index (BMI) were recruited between October 2012 and April 2013 as part of a larger, randomised controlled trial within 42 rural towns. Measured weight and height as well as self-reported measures of individual health, physical activity, dietary intake, self-management, social support and environmental perception were collected. Statistical analysis included linear regression for continuous variables as well as chi-squared and logistic regression for categorical variables with all results adjusted for clustering. RESULTS: 649 women with a mean baseline age and BMI of 39.6±6.7 years and 28.8±6.9 kg/m2 respectively, were studied. Overall, 65% were overweight or obese and 60% overall reported recent weight gain. There was a high intention to self-manage weight, with 68% attempting to lose weight recently, compared to 20% of women reporting health professional engagement for weight management. Obese women reported increased weight gain, energy intake, sitting time and prevalence of pre-existing health conditions. There was an inverse relationship between increased weight and scores for self-management, social support and health environment perception. CONCLUSIONS: Many women in rural communities reported recent weight gain and were attempting to self-manage their weight with little external support. Implications for public health: Initiatives to prevent weight gain require a multifaceted approach, with self-management strategies and social support in tandem with building a positive local environmental perception.

Optimizing Implementation of Obesity Prevention Programs: A Qualitative Investigation Within a Large-Scale Randomized Controlled Trial.

PURPOSE: The prevalence of obesity in rural and remote areas is elevated in comparison to urban populations, highlighting the need for interventions targeting obesity prevention in these settings. Implementing evidence-based obesity prevention programs is challenging. This study aimed to investigate factors influencing the implementation of obesity prevention programs, including adoption, program delivery, community uptake, and continuation, specifically within rural settings. METHODS: Nested within a large-scale randomized controlled trial, a qualitative exploratory approach was adopted, with purposive sampling techniques utilized, to recruit stakeholders from 41 small rural towns in Australia. In-depth semistructured interviews were conducted with clinical health professionals, health service managers, and local government employees. Open coding was completed independently by 2 investigators and thematic analysis undertaken. FINDINGS: In-depth interviews revealed that obesity prevention programs were valued by the rural workforce. Program implementation is influenced by interrelated factors across: (1) contextual factors and (2) organizational capacity. Key recommendations to manage the challenges of implementing evidence-based programs focused on reducing program delivery costs, aided by the provision of a suite of implementation and evaluation resources. Informing the scale-up of future prevention programs, stakeholders highlighted the need to build local rural capacity through developing supportive university partnerships, generating local program ownership and promoting active feedback to all program partners. CONCLUSION: We demonstrate that the rural workforce places a high value on obesity prevention programs. Our results inform the future scale-up of obesity prevention programs, providing an improved understanding of strategies to optimize implementation of evidence-based prevention programs.

Engaging rural women in healthy lifestyle programs: insights from a randomized controlled trial.

BACKGROUND: The obesity epidemic is well established, particularly in rural settings. Programs promoting healthy lifestyles for rural women are urgently needed; however, participant engagement is challenging. In the context of a large randomized controlled trial targeting the prevention of weight gain in rural women, we explored successful recruitment strategies and aimed to understand participants' barriers, enablers and reasons for program participation. METHODS: We recruited women (aged 18-55 years) from the general rural Australian population. A mixed-methods approach was applied to explore factors that influenced program participation, including quantitative questionnaires for all participants (n = 649) and qualitative semi-structured interviews conducted for a subgroup of participants (n = 45). Data were collected at three time points: baseline, 6 and 12 months post program commencement. RESULTS: We recruited 649 rural women through a community communication and partnering strategy, a program marketing campaign and mobilization of social networks. Program participants were diverse across education and income levels and were representative of the wider Australian regional population. Factors that influenced program engagement were divided into personal (perceived program benefits and program accessibility) and social (peer persuasion and support). Identified enablers included convenience of the program location, perceived program utility, such as weight management and optimization of lifestyle choices, as well as attending the program with peer support. Barriers to engagement, which are likely exacerbated in rural communities included lack of anonymity, self-consciousness and segregated social networks in rural settings. Participants reported that eliciting local support and maximizing publicity is fundamental to improving future program engagement. CONCLUSION: Multiple program promotion strategies including communication, marketing and partnering, as well as mobilization of social networks and peer persuasion, enabled engagement of rural women into a healthy lifestyle program. These recruitment strategies are consistent with successful strategies utilized previously to recruit urban-dwelling women into lifestyle programs. Future engagement efforts in rural settings could be enhanced by hosting multiple sessions within existing socio-cultural networks and assuring participants that they will not need to share their personal health information with others in their community. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry. Trial number ACTRN12612000115831. Date of registration 24 January 2012.

Limiting postpartum weight retention through early antenatal intervention: the HeLP-her randomised controlled trial.

BACKGROUND: Pregnancy is a recognised high risk period for excessive weight gain, contributing to postpartum weight retention and obesity development long-term. We aimed to reduce postpartum weight retention following a low-intensity, self-management intervention integrated with routine antenatal care during pregnancy. METHODS: 228 women at increased risk of gestational diabetes, <15 weeks gestation were randomised to intervention (4 self-management sessions) or control (generic health information). Outcomes, collected at baseline and 6 weeks postpartum, included anthropometrics (weight and height), physical activity (pedometer) and questionnaires (health behaviours). RESULTS: Mean age (32.3 ± 4.7 and 31.7 ± 4.4 years) and body mass index (30.4 ± 5.6 and 30.3 ± 5.9 kg/m2) were similar between intervention and control groups, respectively at baseline. By 6 weeks postpartum, weight change in the control group was significantly higher than the intervention group with a between group difference of 1.45 ± 5.1 kg (95% CI: -2.86,-0.02; p < 0.05) overall, with a greater difference in weight found in overweight, but not obese women. Intervention group allocation, higher baseline BMI, GDM diagnosis, country of birth and higher age were all independent predictors of lower weight retention at 6 weeks postpartum on multivariable linear regression. Other factors related to weight including physical activity, did not differ between groups. CONCLUSIONS: A low intensity intervention, integrated with standard antenatal care is effective in limiting postpartum weight retention. Implementation research is now required for scale-up to optimise antenatal health care. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry Number: ACTRN12608000233325. Registered 7/5/2008.

Effectiveness and implementation of an obesity prevention intervention: the HeLP-her Rural cluster randomised controlled trial.

BACKGROUND: To impact on the obesity epidemic, interventions that prevent weight gain across populations are urgently needed. However, even the most efficacious interventions will have little impact on obesity prevention unless they are successfully implemented in diverse populations and settings. Implementation research takes isolated efficacy studies into practice and policy and is particularly important in obesity prevention where there is an urgent need to accelerate the evidence to practice cycle. Despite the recognised need, few obesity prevention interventions have been implemented in real life settings and to our knowledge rarely target rural communities. METHODS: Here we describe the rationale, design and implementation of a Healthy Lifestyle Program for women living in small rural communities (HeLP-her Rural). The primary goal of HeLP-her Rural is to prevent weight gain using a low intensity, self-management intervention. Six hundred women from 42 small rural communities in Australia will be randomised as clusters (n-21 control towns and n = 21 intervention towns). A pragmatic randomised controlled trial methodology will test efficacy and a comprehensive mixed methods community evaluation and cost analysis will inform effectiveness and implementation of this novel prevention program. DISCUSSION: Implementing population interventions to prevent obesity is complex, costly and challenging. To address these barriers, evidence based interventions need to move beyond isolated efficacy trials and report outcomes related to effectiveness and implementation. Large pragmatic trials provide an opportunity to inform both effectiveness and implementation leading to potential for greater impact at the population level. Pragmatic trials should incorporate both effectiveness and implementation outcomes and a multidimensional methodology to inform scale-up to population level. The learnings from this trial will impact on the design and implementation of population obesity prevention strategies nationally and internationally. TRIAL REGISTRATION: ANZ clinical trial registry ACTRN12612000115831. Date of registration 24/01/2012.

How effective is self-weighing in the setting of a lifestyle intervention to reduce gestational weight gain and postpartum weight retention?

Self-weighing is important for weight management in general populations; however its role in optimising gestational weight gain is less clear. Our randomised trial in early pregnancy found regular self-weighing when combined with a self-management intervention, optimised weight gain at 28 weeks gestation (5.66 ± 2.6 kg vs 7.03 ± 3.56 kg, P = 0.02) and reduced postpartum weight retention (-0.57 ± 3.94 kg vs 1.48 ± 5.49 kg, P < 0.05) compared with control participants. Results highlight the importance of self-monitoring strategies during pregnancy.

Optimizing healthy gestational weight gain in women at high risk of gestational diabetes: a randomized controlled trial.

OBJECTIVE: Optimizing gestational weight gain (GWG) in early pregnancy is of clinical and public health importance, especially in higher risk pregnancies. DESIGN AND METHODS: In a robustly designed, randomized controlled trial, 228 pregnant women at risk of developing gestational diabetes mellitus (GDM) were allocated to either control (written health information only) or intervention (four-session lifestyle program). All women received standard maternal care. Measures were completed at 12-15 and 26-28 weeks gestation. Measures included anthropometrics (weight and height), physical activity (pedometer and International Physical Activity Questionnaire), questionnaires (risk perception), and GDM screening. RESULTS: The mean (SD) age [31.7 (4.5) and 32.4 (4.7) years] and body mass index [BMI; 30.3 (5.9) and 30.4 (5.6) kg/m(2) ] were similar between control and intervention groups, respectively. By 28 weeks, GWG was significantly different between control and intervention groups [6.9 (3.3) vs. 6.0 (2.8) kg, P < 0.05]. When stratified according to baseline BMI, overweight women in the control group gained significantly more weight compared to overweight women in the intervention group [7.8 (3.4) vs. 6.0 (2.2) kg, P < 0.05], yet in obese women, GWG was similar in both groups. Physical activity levels declined by 28 weeks gestation overall (P < 0.01); however, the intervention group retained a 20% higher step count compared to controls [5,203 (3,368) vs. 4,140 (2,420) steps/day, P < 0.05]. Overall, GDM prevalence was 22.8% [Corrected], with a trend toward less cases in the intervention group (P = 0.1). CONCLUSIONS: Results indicate that a low-intensity lifestyle intervention, integrated with antenatal care, optimizes healthy GWG and attenuates physical activity decline in early pregnancy. Efficacy in limiting weight gain was greatest in overweight women and in high-risk ethnically diverse women.

Measuring physical activity during pregnancy.

BACKGROUND: Currently, little is known about physical activity patterns in pregnancy with prior estimates predominantly based on subjective assessment measures that are prone to error. Given the increasing obesity rates and the importance of physical activity in pregnancy, we evaluated the relationship and agreement between subjective and objective physical activity assessment tools to inform researchers and clinicians on optimal assessment of physical activity in pregnancy. METHODS: 48 pregnant women between 26-28 weeks gestation were recruited. The Yamax pedometer and Actigraph accelerometer were worn for 5-7 days under free living conditions and thereafter the International Physical Activity Questionnaire (IPAQ) was completed. IPAQ and pedometer estimates of activity were compared to the more robust and accurate accelerometer data. RESULTS: Of 48 women recruited, 30 women completed the study (mean age: 33.6 ± 4.7 years; mean BMI: 31.2 ± 5.1 kg/m(2)) and 18 were excluded (failure to wear [n = 8] and incomplete data [n = 10]). The accelerometer and pedometer correlated significantly on estimation of daily steps (ρ = 0.69, p < 0.01) and had good absolute agreement with low systematic error (mean difference: 505 ± 1498 steps/day). Accelerometer and IPAQ estimates of total, light and moderate Metabolic Equivalent minutes/day (MET min(-1) day(-1)) were not significantly correlated and there was poor absolute agreement. Relative to the accelerometer, the IPAQ under predicted daily total METs (105.76 ± 259.13 min(-1) day(-1)) and light METs (255.55 ± 128.41 min(-1) day(-1)) and over predicted moderate METs (-112.25 ± 166.41 min(-1) day(-1)). CONCLUSION: Compared with the accelerometer, the pedometer appears to provide a reliable estimate of physical activity in pregnancy, whereas the subjective IPAQ measure performed less accurately in this setting. Future research measuring activity in pregnancy should optimally encompass objective measures of physical activity. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry Number: ACTRN12608000233325. Registered 7/5/2008.

Exercise therapy in polycystic ovary syndrome: a systematic review.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common endocrine disorder, affecting 8-12% of women. Lifestyle modification, including increased physical activity, is the first-line approach in managing PCOS. A systematic review was performed to identify and describe the effect of exercise as an independent intervention on clinical outcomes in PCOS. METHODS: Five databases were searched with no time limit. A pre-specified definition of PCOS was not used. Studies were included if exercise therapy (aerobic and/or resistance) could be evaluated as an independent treatment against a comparison group. Outcomes measured included cardiovascular risk factors [insulin resistance (IR), lipid profiles, blood pressure and weight] and reproductive measures (ovulation, menstrual regularity and fertility outcomes). Quality analysis was performed based on the Cochrane Handbook of Systematic Reviews and the Quality of Reporting of Meta-Analyses checklist. RESULTS: Eight manuscripts were identified (five randomized controlled trials and three cohort studies). All studies involved moderate intensity physical activity and most were of either 12 or 24 weeks duration with frequency and duration of exercise sessions ranging between studies. The most consistent improvements included improved ovulation, reduced IR (9-30%) and weight loss (4.5-10%). Improvements were not dependant on the type of exercise, frequency or length of exercise sessions. CONCLUSIONS: Exercise-specific interventions in PCOS are limited. Studies vary considerably in design, intensity and outcome measures; therefore conclusive results remain elusive. Larger, optimally designed studies are needed to both gain insights into the mechanisms of exercise action and to evaluate the public health impact of exercise of PCOS.

Polycystic ovary syndrome and weight management.

Polycystic ovary syndrome (PCOS) is a common condition in women of reproductive age, and has reproductive, metabolic and psychological implications. Weight gain and obesity worsen the features of PCOS, while weight loss improves the features of PCOS. While there are potential barriers to successful weight management in young women who do not suffer from PCOS, women with PCOS may experience additional barriers. Weight management strategies in younger women with or without PCOS should encompass both the prevention of excess weight gain and achieving and maintaining a reduced weight through multidisciplinary lifestyle management, comprising dietary, exercise and behavioral therapy, as well as attention to psychosocial stress and practical and physiological barriers to weight management. Further research is warranted in the examination of specific barriers to weight management in women with PCOS, as well as in the determination of optimal components of lifestyle weight management interventions in young women in order to facilitate long-term compliance.

A systematic review of interventions aimed at the prevention of weight gain in adults.

OBJECTIVE: The WHO has recommended that prevention of overweight and obesity should begin early and target adults, including those with an acceptable BMI. The aim of the present paper was to systematically review published interventions with a specific stated aim to prevent weight gain. DESIGN: Five databases were searched to July 2008. The reference lists of review articles and obesity society meetings abstracts were hand searched. Interventions were included if the primary aim was to prevent weight gain and they included a comparison group. RESULTS: Ten publications were included, describing nine separate interventions in adults of various ages and target populations. All interventions incorporated diet and physical activity with behaviour change strategies. Most studies were between 1 and 3 years in duration. Five studies reported a significant difference in weight between intervention and control subjects of between 1.0 and 3.5 kg, due largely to an increase in weight in the control group. However, there was a lack of consistent, clear, psychological models and a failure to identify successful components. More intensive interventions were not always successful, nor were mail-only or clinic-based interventions. In contrast, interventions that included mixed modes of delivery with some personal contact were successful. CONCLUSIONS: There were relatively few trials aimed at the prevention of weight gain. Existing trials varied by intensity, delivery methods, target groups and study components, and therefore provide limited opportunities for comparison of effect size. Further large, effective, evidence-based programmes are urgently needed in the general population as well as high-risk groups.

Weight, physical activity and dietary behavior change in young mothers: short term results of the HeLP-her cluster randomized controlled trial.

BACKGROUND: Preventing weight gain rather than treating established obesity is an important economic and public health response to the rapidly increasing rates of obesity worldwide. Treatment of established obesity is complex and costly requiring multiple resources. Preventing weight gain potentially requires fewer resources to reach broad population groups, yet there is little evidence for successful interventions to prevent weight gain in the community. Women with children are an important target group because of high rates of weight gain and the potential to influence the health behaviors in family members. METHODS: The aim of this cluster randomized controlled trial was to evaluate the short term effect of a community-based self-management intervention to prevent weight gain. Two hundred and fifty mothers of young children (mean age 40 years +/- 4.5, BMI 27.9 kg/m2 +/- 5.6) were recruited from the community in Melbourne, Australia. The intervention group (n = 127) attended four interactive group sessions over 4 months, held in 12 local primary schools in 2006, and was compared to a group (n = 123) receiving a single, non-interactive, health education session. Data collection included self-reported weight (both groups), measured weight (intervention only), self-efficacy, dietary intake and physical activity. RESULTS: Mean measured weight decreased significantly in the intervention group (-0.78 kg 95% CI; -1.22 to -0.34, p < 0.001). Comparing groups using self-reported weight, both the intervention and comparison groups decreased weight, -0.75 kg (95% CI; -1.57 to 0.07, p = 0.07) and -0.72 kg (95% CI; -1.59 to 0.14 p = 0.10) respectively with no significant difference between groups (-0.03 kg, 95% CI; -1.32 to 1.26, p = 0.95). More women lost or maintained weight in the intervention group. The intervention group tended to have the greatest effect in those who were overweight at baseline and in those who weighed themselves regularly. Intervention women who rarely self-weighed gained weight (+0.07 kg) and regular self-weighers lost weight (-1.66 kg) a difference of -1.73 kg (95% CI; -3.35 to -0.11 p = 0.04). The intervention reported increased physical activity although the difference between groups did not reach significance. Both groups reported replacing high fat foods with low fat alternatives and self-efficacy deteriorated in the comparison group only. CONCLUSION: Both a single health education session and interactive behavioral intervention will result in a similar weight loss in the short term, although more participants in the interactive intervention lost or maintained weight. There were small non-significant changes to physical activity and changes to fat intake specifically replacing high fat foods with low fat alternatives such as fruit and vegetables. Self-monitoring appears to enhance weight loss when part of an intervention. TRIAL REGISTRATION: ACTRN12608000110381.