Effect of Diets Varying in Iron and Saturated Fat on the Gut Microbiota and Intestinal Inflammation: A Crossover Feeding Study among Older Females with Obesity.

Obesity is considered an independent risk factor for colorectal cancer (CRC). Altered nutrient metabolism, particularly changes to digestion and intestinal absorption, may play an important role in the development of CRC. Iron can promote the formation of tissue-damaging and immune-modulating reactive oxygen species. We conducted a crossover, controlled feeding study to examine the effect of three, 3-week diets varying in iron and saturated fat content on the colonic milieu and systemic markers among older females with obesity. Anthropometrics, fasting venous blood and stool were collected before and after each diet. There was a minimum 3-week washout period between diets. Eighteen participants consumed the three diets (72% Black; mean age 60.4 years; mean body mass index 35.7 kg/m2). Results showed no effect of the diets on intestinal inflammation (fecal calprotectin) or circulating iron, inflammation, and metabolic markers. Pairwise comparisons revealed less community diversity between samples (beta diversity, calculated from 16S rRNA amplicon sequences) among participants when consuming a diet low in iron and high in saturated fat vs. when consuming a diet high in iron and saturated fat. More studies are needed to investigate if dietary iron represents a salient target for CRC prevention among individuals with obesity.

Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial.

Importance: Contextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag. Objective: To determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags. Design, Setting, and Participants: This randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis. Interventions: Patients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician's note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders. Main Outcomes and Measures: Proportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit. Results: Four hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]). Conclusions and Relevance: This randomized clinical trial found that contextualized CDS did not improve patients' outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03244033.

Addressing Women's Health Care Needs During Pediatric Care.

Objective: To determine if the use of a simple self-administered Postpartum Questionnaire for Mothers (PQM) at the well-baby visit (WBV) increased the proportion of women who received health care and contraception by 6 months postpartum (PP). Methods: This was a single-site, system-level, intervention. Women were recruited from the pediatric clinic when presenting with their infants for a 2-month WBV. During phase 1 of the study, a control group was enrolled, followed by an 8-week washout period; then enrollment of the intervention group (phase 2). During phase 2, the PQM was administered and reviewed by the pediatrician during the infant's visit; the tool prompted the pediatrician to make a referral for the mother's primary or contraceptive care as needed. Data were collected at baseline and at 6 months PP, and additional data were extracted from the electronic medical record. Results: We found that PP women exposed to the PQM during their infant's WBV were more likely to have had a health care visit for themselves between 2 and 6 months PP, compared with the control group (relative risk [RR] 1.66, [confidence interval (CI) 0.91-3.03]). In addition, at 6 months PP, women in the intervention group were more likely to identify a primary care provider (RR 1.84, [CI 0.98-3.46]), and more likely to report use of long-acting reversible contraception (LARC) (RR 1.24, [CI 0.99-1.58]), compared with women in the control group. Conclusion: A simple self-administered PQM resulted in an increase in women's receipt of health care and use of LARC by 6 months PP. Clinical Trial Registration: Use of a reproductive life planning tool at the pediatric well-baby visit with postpartum women, NCT03448289.

Impact of Physical Activity and Weight Loss on Fat Mass, Glucose Metabolism, and Inflammation in Older African Americans with Osteoarthritis.

(1) Background: There are currently very few interventions performed within a community setting that compare the effects of physical activity (PA) versus PA plus weight loss on cancer and chronic disease risk in older African Americans. Therefore, we investigated the impact of an 8 week (24 session) PA intervention compared to a PA plus weight loss intervention on fat mass, glucose metabolism, and markers of inflammation in older, overweight and obese African Americans. (2) Methods: Subjects were randomized to a PA (n = 83) or PA plus weight loss (n = 72) intervention that met three times weekly for 8 weeks. At baseline and post-intervention, anthropometrics, body composition, systemic inflammation (high-sensitivity C-reactive protein, tumor necrosis factor-α, and interleukin 6), fasting glucose, insulin and homeostasis model assessment-insulin resistance (HOMA-IR) were determined. (3) Results: Subjects had a mean age of 67 years (SD = 5.3) and were mostly women (88%). The PA plus weight loss group lost more total and visceral fat than the PA group (-4.0% vs. +0.6% and -4.1% vs. +3.7%, respectively, p < 0.01 for both). Changes in inflammation and glucose metabolism were similar between groups post-intervention. Within the PA plus weight loss group only, serum insulin and HOMA-IR decreased significantly. (4) Conclusions: PA combined with weight loss can decrease total and visceral fat mass and improve insulin sensitivity, confirming that these cancer- and chronic disease-related risk factors are influenced by relatively modest lifestyle changes in the short term.

Physical Activity Changes during Pregnancy in a Comparative Impact Trial.

OBJECTIVES: Delta Healthy Sprouts was designed to test the comparative impact of 2 home visiting curricula on weight status, dietary intake, physical activity, and other health behaviors of rural, southern African-American women and their infants. Results pertaining to physical activity outcomes in the gestational period are reported. METHODS: Eighty-two women, early in their second trimester of pregnancy, were enrolled and randomly assigned to one of 2 treatment arms. Self-reported physical activity was measured 3 times in the gestational period (gestational months 4, 6 and 8). Generalized linear mixed models were used to test for significant treatment, time, and treatment by time effects on weekly minutes of moderate-to-vigorous physical activity (MVPA). RESULTS: Significantly less MVPA was performed at gestational month 8 when compared with gestational month 4 (enrollment) for both treatment arms. Statistically significant effects were not found for treatment or treatment by time interaction. CONCLUSIONS: Neither the Parents as Teachers (control) curriculum nor the Parents as Teachers Enhanced intervention proved effective at increasing or maintaining MVPA in this cohort of pregnant women. Lack of adequate physical activity in pregnancy remains an important public health concern, especially given its known health benefits.

Gestational Weight Gain: Results from the Delta Healthy Sprouts Comparative Impact Trial.

Introduction. Delta Healthy Sprouts trial was designed to test the comparative impact of two home visiting programs on weight status, dietary intake, and health behaviors of Southern African American women and their infants. Results pertaining to the primary outcome, gestational weight gain, are reported. Methods. Participants (n = 82), enrolled early in their second trimester of pregnancy, were randomly assigned to one of two treatment arms. Gestational weight gain, measured at six monthly home visits, was calculated by subtracting measured weight at each visit from self-reported prepregnancy weight. Weight gain was classified as under, within, or exceeding the Institute of Medicine recommendations based on prepregnancy body mass index. Chi-square tests and generalized linear mixed models were used to test for significant differences in percentages of participants within recommended weight gain ranges. Results. Differences in percentages of participants within the gestational weight gain guidelines were not significant between treatment arms across all visits. Conclusions. Enhancing the gestational nutrition and physical activity components of an existing home visiting program is feasible in a high risk population of primarily low income African American women. The impact of these enhancements on appropriate gestational weight gain is questionable given the more basic living needs of such women. This trial is registered with ClinicalTrials.gov NCT01746394, registered 4 December 2012.

Maternal diet quality and nutrient intake in the gestational period: results from the delta healthy sprouts comparative impact trial.

BACKGROUND: A woman's diet while pregnant can play an important role in her reproductive health as well as the health of her unborn child. Diet quality and nutrient intake amongst pregnant women residing in the rural Lower Mississippi Delta (LMD) region of the United States is inadequate. The Delta Healthy Sprouts Project was designed to test the comparative impact of two home visiting programs on weight status, dietary intake, and health behaviors of women and their infants residing in the LMD region. This paper reports results pertaining to maternal diet quality and nutrient intake in the gestational period. METHODS: The experimental arm (PATE) received monthly home visits beginning in the second trimester using the Parents as Teachers curriculum enhanced with a nutrition and lifestyle behavior curriculum. The control arm (PAT) received monthly home visits using the Parents as Teachers curriculum only. Maternal diet was assessed via 24-h dietary recall at gestational months (GM) 4 (baseline), 6, and 8. Diet quality was computed using the Healthy Eating Index-2010 (HEI-2010). RESULTS: Gestational period retention rates for PAT and PATE arms were 77 % (33/43) and 67 % (26/39), respectively. Significant effects were not found for time, treatment, or time by treatment for the HEI-2010 total or component scores, macro- or micronutrient intake or percentage of women meeting recommended nutrient intakes. CONCLUSIONS: Perhaps due to low participant enrollment and higher than expected rates of drop out and noncompliance, we were not able to demonstrate that the enhanced nutrition and lifestyle curriculum (PATE) intervention had a significant effect on diet quality or nutrient intake during pregnancy in this cohort of rural, Southern, primarily African American women. TRIAL REGISTRATION: clinicaltrials.gov, NCT01746394. Registered 5 December 2012.

Baseline Demographic, Anthropometric, Psychosocial, and Behavioral Characteristics of Rural, Southern Women in Early Pregnancy.

Objectives Beginning life in a healthy uterine environment is essential for future well-being, particularly as it relates to chronic disease risk. Baseline (early pregnancy) demographic, anthropometric (height and weight), psychosocial (depression and perceived stress), and behavioral (diet and exercise) characteristics of rural, Southern, pregnant women enrolled in a maternal, infant, and early childhood home visiting program are described. Methods Participants included 82 women early in their second trimester of pregnancy and residing in three Lower Mississippi Delta counties in the United States. Baseline data were collected through direct measurement and surveys. Results Participants were primarily African American (96 %), young (mean age = 23 years), single (93 %), and received Medicaid (92 %). Mean gestational age was 18 weeks, 67 % of participants were overweight or obese before becoming pregnant, and 16 % tested positive for major depression. Participants were sedentary (mean minutes of moderate intensity physical activity/week = 30), had low diet quality (mean Healthy Eating Index-2010 total score = 43 points), with only 38, 4, and 7 % meeting recommendations for saturated fat, fiber, and sodium intakes, respectively. Conclusions for Practice In the Lower Mississippi Delta, there is a need for interventions that are designed to help women achieve optimal GWG by improving their diet quality and increasing the amount of physical activity performed during pregnancy. Researchers also should consider addressing barriers to changing health behaviors during pregnancy that may be unique to this region of the United States.

Low rate of initiation and short duration of breastfeeding in a maternal and infant home visiting project targeting rural, Southern, African American women.

BACKGROUND: Despite the benefits of breastfeeding for both infant and mother, rates in the United States remain below Healthy People 2020 breastfeeding objectives. This paper describes breastfeeding outcomes of the Delta Healthy Sprouts participants during gestational and postnatal periods. Of specific interest was whether breastfeeding intent, knowledge, and beliefs changed from the early to late gestational period. Additionally, analyses were conducted to test for associations between breastfeeding initiation and breastfeeding intent, knowledge and beliefs as well as sociodemographic characteristics and other health measures. METHODS: Eighty-two pregnant women were enrolled in this project spanning three Mississippi counties. Participants were randomly assigned to one of two treatment groups. Because both groups received information about breastfeeding, breastfeeding outcomes were analyzed without regard to treatment assignment. Hence participants were classified into two groups, those that initiated breastfeeding and those that did not initiate breastfeeding. Generalized linear mixed models were used to test for significant group, time, and group by time effects on breastfeeding outcomes. RESULTS: Breastfeeding knowledge scores increased significantly from baseline to late gestational period for both groups. Across time, breastfeeding belief scores were higher for the group that initiated breastfeeding as compared to the group that did not breastfeed. Only 39% (21 of 54) of participants initiated breastfeeding. Further, only one participant breastfed her infant for at least six months. Breastfeeding intent and beliefs as well as pre-pregnancy weight class significantly predicted breastfeeding initiation. CONCLUSIONS: Our findings indicate that increasing knowledge about and addressing barriers for breastfeeding were insufficient to empower rural, Southern, primarily African American women to initiate or continue breastfeeding their infants. Improving breastfeeding outcomes for all socioeconomic groups will require consistent, engaging, culturally relevant education that positively influences beliefs as well as social and environmental supports that make breastfeeding the more accepted, convenient, and economical choice for infant feeding. TRIAL REGISTRATION: clinicaltrials.gov NCT01746394. Registered 5 December 2012.