Value, implementation, and opportunities for cardiovascular behavioral medicine: A special issue commentary.

Behavioral and psychosocial factors related to the incidence, progression, and treatment of cardiovascular health, have seen increased attention in recent years, from scientific statements to a robust and growing body of literature. Despite this attention, and clear need to prevent and treat cardiovascular disease (CVD) the world over, implementation of cardiovascular behavioral medicine, specialty care that addresses behavioral and psychosocial risk factors among those with, or at risk for, CVD, remains limited. The current commentary discusses the contributions of the diverse body of science published in the Cardiovascular Behavioral Medicine Special Issue of Health Psychology. The authors outline how the special issue articles highlight the value of behavioral medicine education, science, and clinical practice for cardiology and cardiovascular subspecialities, such as heart failure, as well as opportunities for growth and implementation. This commentary outlines the ways in which the special issue furthers understanding of the current and future possibilities for cardiovascular behavioral medicine to grow as a field and influence cardiovascular health and wellbeing. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mobile assessment of experiential avoidance, mood, stress, and attendance in cardiopulmonary rehabilitation.

OBJECTIVES: This study utilized mobile ecological momentary assessment (EMA) to examine the dynamic relationships among experiential avoidance (EA), mood, and cardiopulmonary rehabilitation (CVPR) attendance. METHOD: Participants (n = 47; 40.4% female; 80.1% White; 85.1% Cardiac, 14.9% Pulmonary) were recruited from CVPR during their first 2 weeks of the program. They completed daily EMA prompts to assess momentary mood and EA for 2 weeks using a smartphone device. Multilevel modeling (MLM) was employed to investigate the impact of EA and mood on next-week attendance and the within-person within-prompt correlates, antecedents, and consequences of EA. RESULTS: Greater EA and negative mood significantly predicted worse next-week CVPR attendance rates. Within the same EMA prompt individuals with higher EA also reported greater negative affect and perceived stress, while individuals with lower EA reported greater positive mood. In addition, lagged analyses showed that EA was negatively related to next-day positive mood scores. CONCLUSIONS: EA appears to be an important targetable mechanism negatively related to CVPR program attendance and mood in CVPR patients. The present study builds upon previous research supporting EA as a dynamic and fluid emotion-regulation process, suggesting EA's impact on mood and behavior may be best understood through repeated real-time measurement methodology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process. METHODS: First, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions). RESULTS: The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising. CONCLUSIONS: BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04158219.

Life-space constriction in aging adults.

BACKGROUND: Early indicators of declining function and frailty, such as life-space constriction (LSC), are important in identifying those at risk for frailty. PURPOSE: Examine factors associated with LSC and the influence on function and frailty. METHODS: A cross-sectional, descriptive study was conducted using a convenience sample of community dwelling persons 55 and older living in the South. RESULTS: Most participants (N = 72) were female (69%; n = 50) and half were White (53.5%; n = 38). Individual factors including challenges (age-related physiological changes, disease burden, mental health limitations) and buoy (assistive devices, and other compensatory strategies) explained 22% variance in self-reported frailty (F = 3.099 (6, 65); p = .01). LSC explained 34% variance in function (F = 3.805 (8, 59); p = .001) when environmental supports (family ties, and social network) and challenges (area deprivation, built environment, and social disorganization) and individual factors were controlled for. Number of assistive devices was the only significant predictor of frailty.

Sharing the Story of the Cardiac Rehab Patient Experience: A QUALITATIVE STUDY.

PURPOSE: To provide a prototypical patient narrative of the cardiac rehabilitation (CR) experience for providers and prospective patients using narrative analysis. METHODS: Qualitative interviews with 17 CR patients from a previous study regarding their experiences, reasons, and motivations related to engagement in CR were analyzed using narrative inquiry. Interviews were previously analyzed and coded for recurring themes, and these themes were implemented in an exploratory narrative inquiry to craft a CR patient "story." A hypothetical composite character representing the varied experiences of CR patients interviewed was developed, and a patient story was constructed that reflected on an initial cardiac event, time during rehabilitation, difficult experiences, social interactions, and personal values and accomplishments. RESULTS: The CR patient narrative is presented for use in CR recruitment and programming materials, and in provider education. CONCLUSION: The narrative analysis comprehensively provides patients with an amalgam of patient experiences and can be used by providers to gain an understanding of CR patient experiences. Further research is needed to determine whether use of the resulting narrative analysis within the referral process and/or programming could increase participation and engagement.

Does it Matter What We Drink? Beverage Type Preference Predicts Specific Alcohol-Related Negative Consequences Among College Students.

BACKGROUND: College student substance use has been a problem for many years. In particular, heavy alcohol consumption can create issues with academics, social relationships, and overall functioning. Unitary measures of generic alcohol consumption (e.g., drinking frequency) are important predictors of alcohol-related negative consequences, but the small amount of specific-beverage research available suggests that assessing beverage type consumed may enhance prediction. OBJECTIVES: The purpose of the present study was to expand knowledge of alcoholic beverage preference in relation to negative consequences and confirm the factor structure of the RAPI proposed by Martens et al. ( 2007 ) in a college student sample. METHODS: In addition, the present study expanded current knowledge by assessing beverage preference type in relation to specific negative consequences on the RAPI. RESULTS: Results replicated the three-factor structure originally found by Martens et al. ( 2007 ). Moreover, results found that individuals consuming shots of liquor or alcohol mixed with caffeine reported higher overall RAPI scores and higher scores on the Abuse/Dependence and Personal Consequences factors but not the Social Consequences factor than those consuming mixed drinks, beer, or wine. Conclusions/Importance: This research might inform discussions with incoming college freshman about not only alcohol consumption and negative consequences but the dangers of drinking specific types of alcohol beverages such as shots and/or alcohol mixed with caffeine.

An Exploration of the Impact of the "Open Gym" Scheduling Model of Cardiovascular Rehabilitation on Completion, Attendance, and Health Outcomes.

PURPOSE: To explore the effects of implementation of the "Open Gym" (OG) scheduling model of cardiovascular rehabilitation administration on the rate of patient engagement and change in commonly measured clinical outcomes. Little data exist on the potential benefits of the OG model on patient completion, attendance, and clinical outcomes. METHODS: A retrospective chart review was conducted that included the 1-y period both before and after OG model implementation. Bootstrapped regression and analysis of variance were utilized to determine (1) whether the scheduling model is associated with number of sessions attended and program completion, and (2) among those who meet their goals and thus complete the program, if the scheduling model predicts change in cardiovascular rehabilitation clinical outcomes (ie, percent weight change, 6-min walk distance, and peak metabolic equivalents during exercise) when controlling for baseline values. Follow-up analyses controlled for and explored interactions related to age, race, and sex. RESULTS: In this racially diverse sample (34% nonwhite), patients under either the OG model (n = 125) or the Traditional model (n = 82) attended an equivalent number of sessions and were just as likely to complete their treatment. However, clinical outcomes favored the Traditional model, even as more patients participated in the OG model, especially racial minority patients. CONCLUSIONS: Although the OG model is more consistent with patient-centered care, gains in functional capacity may be diminished. Furthermore, better controlled experiments are needed to examine the effects of implementing the OG model and should include measures of possible mechanisms influencing racial differences.

Improvements in Depressive Symptoms and Affect During Cardiac Rehabilitation: PREDICTORS AND POTENTIAL MECHANISMS.

PURPOSE: Depression is indicative of poor prognosis in cardiac patients. Reductions in depression have been observed following cardiac rehabilitation (CR). Whether similar improvements in positive and negative affect occur is unknown. Greater understanding of depressive symptom and affect change is needed to enhance facilitators of emotional improvement after a cardiac event. METHODS: Cardiac rehabilitation attendees (n = 637) completed measures of depressive symptoms, affect, health status, and social support at CR intake and discharge. Body mass index, metabolic equivalents, and blood pressure were also measured. Relationships between changes in psychosocial and physical health indicators and depressive symptoms, positive affect, and negative affect were examined. RESULTS: From intake to discharge, depressive symptoms (d = 0.40, P < .001) and negative affect (d = 0.26, P < .001) decreased. Positive affect increased (d = 0.34, P < .001). In multivariate regression, predictors of depressive symptom reduction were increased vitality (ß = -.26) and decreased bodily pain (ß = -.08). Predictors of positive affect increase were increased vitality (ß = .25), social support (ß = .16), and physical role functioning (ß = .09). Predictors of negative affect reduction were increased vitality (ß = -.23) and social support (ß = -.10). Changes in indicators of physical health were not related to depressive symptom or affect change. CONCLUSIONS: Depressive symptom and affect improvements following CR were observed and most strongly associated with improvements in vitality and social support. Future research should explore how enhancement of these mechanisms may further improve depressive symptom and affect during CR.

Psychosocial factors associated with treatment outcomes in women with obesity and major depressive disorder who received behavioral activation for depression.

Behavioral activation is an empirically supported treatment for depression, but much is unknown about factors associated with treatment response. The present study aimed to determine whether baseline levels and subsequent changes in psychosocial factors were associated with improvement in depression in women with comorbid obesity who received behavioral activation treatment for depression and a lifestyle intervention. Multilevel modeling was used to estimate the associations between psychosocial factors and change in depression scores during the first 10 weeks of treatment and associations between changes in psychosocial factors from baseline to 6-month follow-up and change in depression over the same time period. No baseline psychosocial factors were associated with depression improvement during treatment (p = 0.110-0.613). However, greater improvement in hedonic capacity (p = 0.001), environmental reward (p = 0.004), and social impairment (p = 0.012) were associated with greater reductions in depression over 6 months. Findings highlight the differential relationship specific psychosocial factors have with depression treatment outcomes.

A functional description of adult picky eating using latent profile analysis.

OBJECTIVE: Research has indicated that adult picky eating (PE) is associated with elevated psychosocial impairment and limited dietary variety and fruit and vegetable intake; however, research operationalizing PE behaviors is limited. Previous research identified a PE profile in children, marked by high food avoidance (satiety responsiveness, fussiness, and slow eating) and low food approach (food enjoyment and responsiveness) appetitive traits. The present study aimed to replicate a similar latent eating behavior profile in an adult sample. METHODS: A sample of 1339 US adults recruited through Amazon's MTurk completed an online survey that included a modified self-report version of the Child Eating Behavior Questionnaire (CEBQ-A). Latent profile analysis was employed to identify eating profiles using the CEBQ-A subscales, ANCOVAs were employed to examine profile differences on various self-report measures, and eating profiles were compared across BMI classifications. RESULTS: Analyses converged on a four-profile solution, and a picky eater profile that closely resembled the past child profile emerged. Participants in the picky eater profile (18.1%) scored higher on measures of adult PE and social eating anxiety compared to all other profiles, scored higher on eating-related impairment and depression than moderate eating profiles, and were more likely to be of normal weight. DISCUSSION: A distinct adult PE profile was observed, indicating childhood PE and appetitive behaviors may carry over into adulthood. Research identifying meaningful groups of picky eaters will help to shed light on the conditions under which picky eating is a risk factor for significant psychosocial impairment or distress, or weight-related problems.

Picky eating and fruit and vegetable consumption in college students.

Picky eating (PE) may be an important individual-level factor related to fruit and vegetable (F&V) consumption in adulthood. Past studies showing negative relationships between Adult PE and F&V servings and variety have been limited by measurement issues. The purpose of the present study was replicate these relationships in college students using a well-validated F&V screener and comprehensive measure of adult PE. 1219 college students completed an online survey which included measures of adult PE, F&V daily servings, F&V variety, and other eating behaviors. Partial correlations were calculated, controlling for demographic factors and traditional disordered eating behavior, between the variables of interest. Factor analysis was also utilized to confirm the factor structure of the Adult Picky Eating Questionnaire (APEQ) in a college sample. Partial correlations revealed significant negative relationships between PE and measures of F&V servings and variety. Factor analysis confirmed the utility of the APEQ in a college sample. College students who reported higher levels of PE behaviors and attitudes were more likely to eat less fruits and vegetables, and reported lower F&V variety. Given that F&V servings and variety are related to adequate nutrient intake, and greater F&V consumption is a protective factor against chronic disease risk, the rigid inflexible eating patterns associated with adult PE should be further explored in future research aimed at increasing F&V consumption.

Life Values as an Intrinsic Guide for Cardiopulmonary Rehabilitation Program Engagement: A QUALITATIVE ANALYSIS.

PURPOSE: Participation in cardiovascular and pulmonary rehabilitation (CVPR) programs can lead to improved functional abilities and improved quality of life, but attendance and adherence to these programs remain suboptimal. Behavioral therapies have emphasized the importance of life value identification as a guide for goal setting and behavior change for both psychological and physical health conditions. Individuals who choose to engage in behaviors that align with their life values are thought to be intrinsically reinforced. The purpose of the following qualitative study was to interview patients enrolled in CVPR about their own life values and motivating factors related to healthy behavior changes. METHODS: Thirty cardiac or pulmonary patients were recruited from a CVPR program and participated in a semistructured interview about their life values and motivating factors related to program engagement. The data were transcribed and analyzed thematically. RESULTS: Participants identified a wide range of values related to program engagement, and only half of the participants endorsed health as a value. The most frequently endorsed life values included being active, family, and independence. The interviews indicated that, although patients make lifestyle changes in the program to improve their physical health, there are often other values that primarily guide their choice to engage in and maintain lifestyle behaviors. CONCLUSIONS: Life values can serve as a powerful guide for individual behavior change. The present study suggests that the piloting of brief values interventions early in CVPR treatment is warranted and has the potential to improve patient outcomes.

Exploring the relationship between frontal asymmetry and emotional dampening.

Cardiovascular emotional dampening is the term used to describe the inverse relationship between resting blood pressure and emotional responsivity which extends from normotensive to hypertensive ranges. Little is known about its underlying physiological mechanisms, but it is thought to involve some disruption in emotion processing. One area that has yet to be explored in the literature is the relationship between emotional dampening and frontal asymmetry, a psychophysiological indicator for motivational direction and emotional valence bias. The present study explored that relationship using data from a sample of 48 healthy college students. Measures of baseline resting blood pressure and frontal cortical activity were recorded, after which participants completed a series of emotion-related tasks. Results revealed a significant relationship between resting systolic blood pressure and left frontal activity. Likewise, left frontal activity was associated with neutral appraisal of emotionally valenced stimuli within the tasks. The findings from the present study yield support for a link between emotional dampening and left frontal activity. Implications are discussed.

The weight loss blogosphere: an online survey of weight loss bloggers.

Blogging is a form of online journaling that has been increasingly used to document an attempt in weight loss. Despite the prevalence of weight loss bloggers, few studies have examined this population. We examined characteristics of weight loss bloggers and their blogs, including blogging habits, reasons for blogging, like and dislikes of blogging, and associations between blogging activity and weight loss. Participants (N = 194, 92.3 % female, mean age = 35) were recruited from Twitter and Facebook to complete an online survey. Participants reported an average weight loss of 42.3 pounds since starting to blog about their weight loss attempt. Blogging duration significantly predicted greater weight loss during blogging (ß = -3.65, t(185) = -2.97, p = .003). Findings suggest that bloggers are generally successful with their weight loss attempt. Future research should explore what determines weight loss success/failure in bloggers and whether individuals desiring to lose weight would benefit from blogging.

Interest in a Twitter-delivered weight loss program among women of childbearing age.

Weight management through the childbearing years is important, yet few women have access to efficacious weight loss programs. Online social network-delivered programs may increase reach and thus impact. The aim of this study was to gauge interest in a Twitter-based weight loss intervention among women of childbearing age and the feasibility of recruitment via Twitter. We recruited English-speaking women aged 18-45 years (N = 63) from Twitter to complete an anonymous online survey including open-ended questions about program advantages and concerns. Forty percent of participants were obese and 83 % were trying to lose weight. Eighty-one percent were interested in a Twitter-delivered weight loss program. Interest was high in all subgroups (62-100 %). Participants (59 %) cited program advantages, including convenience, support/accountability, and privacy. Concerns (59 %) included questions about privacy, support/accountability, engagement, efficacy, and technology barriers. Research is needed to develop and evaluate social media-delivered interventions, and to develop methods for recruiting participants directly from Twitter.

Obstructive sleep apnea and weight loss treatment outcome among adults with metabolic syndrome.

OBJECTIVE: The purpose of this study was to examine whether adults with obesity and metabolic syndrome who screen as high risk for obstructive sleep apnea (OSA) lose less weight as part of a weight loss intervention than those who screen as low risk. METHOD: We conducted a secondary analysis of a randomized trial comparing 2 weight loss interventions consisting of dietary counseling for adults with obesity and metabolic syndrome. Participants were screened for sleep apnea using a validated screening questionnaire. Percent weight loss was calculated from weight measured at baseline and intervention end (12 months). Weight loss of 5% or greater was considered clinically significant. Multivariate linear and logistic regression models estimated the association between OSA screening status (high vs. low risk) and percent weight loss and clinically significant weight loss, adjusting for relevant covariates including body mass index and sleep duration. RESULTS: Nearly half of participants (45.8%) screened as high risk for OSA. Participants who screened as high risk for OSA lost less weight (1.2% ± 4.2% vs. 4.2% ± 5.3%) and were less likely to lose 5% or greater (24.4% vs. 75.6%) than participants without OSA. CONCLUSION: Among adults with obesity and metabolic syndrome, those at high risk for OSA lost less weight in response to a dietary counseling intervention than adults with low risk of OSA. Routine OSA screening should be considered as part of weight loss treatment programs. Additional research is needed to determine how to tailor weight loss treatment for those with high risk for OSA. (PsycINFO Database Record

Feasibility of Pairing Behavioral Activation With Exercise for Women With Type 2 Diabetes and Depression: The Get It Study Pilot Randomized Controlled Trial.

Major depressive disorder is often comorbid with diabetes and associated with worse glycemic control. Exercise improves glycemic control and depression, and thus could be a parsimonious intervention for patients with comorbid diabetes and major depression. Because patients with diabetes and comorbid depression are often sedentary and lack motivation to exercise, we developed a group exercise intervention that integrates strategies from behavioral activation therapy for depression to increase motivation for and enjoyment of exercise. We conducted a 6-month pilot randomized controlled trial to test the feasibility of the behavioral activation exercise intervention (EX) for women with diabetes and depression. Of the 715 individuals who contacted us about the study, 29 participants were randomized to the EX condition or an enhanced usual care condition (EUC), which represents 4.1% of participants who initially contacted us. Inclusion criteria made recruitment challenging and limits the feasibility of recruiting women with diabetes and depression for a larger trial of the intervention. Retention was 96.5% and 86.2% at 3 and 6months. Participants reported high treatment acceptability; use of behavioral activation strategies and exercise class attendance was acceptable. No condition differences were observed for glycemic control, depressive symptoms, and physical activity, though depressive symptoms and self-reported physical activity improved over time. Compared to participants in the EUC condition, participants in the EX condition reported greater exercise enjoyment and no increase in avoidance behavior over time. Using behavioral activation strategies to increase exercise is feasible in a group exercise setting. However, whether these strategies can be delivered in a less intensive manner to a broader population of sedentary adults, for greater initiation and maintenance of physical activity, deserves further study.

Twitter-Delivered Behavioral Weight-Loss Interventions: A Pilot Series.

BACKGROUND: Lifestyle interventions are efficacious at reducing risk for diabetes and cardiovascular disease but have not had a significant public health impact given high cost and patient and provider burden. OBJECTIVE: Online social networks may reduce the burden of lifestyle interventions to the extent that they displace in-person visits and may enhance opportunities for social support for weight loss. METHODS: We conducted an iterative series of pilot studies to evaluate the feasibility and acceptability of using online social networks to deliver a lifestyle intervention. RESULTS: In Study 1 (n=10), obese participants with depression received lifestyle counseling via 12 weekly group visits and a private group formed using the online social network, Twitter. Mean weight loss was 2.3 pounds (SD 7.7; range -19.2 to 8.2) or 1.2% (SD 3.6) of baseline weight. A total of 67% (6/9) of participants completing exit interviews found the support of the Twitter group at least somewhat useful. In Study 2 (n=11), participants were not depressed and were required to be regular users of social media. Participants lost, on average, 5.6 pounds (SD 6.3; range -15 to 0) or 3.0% (SD 3.4) of baseline weight, and 100% (9/9) completing exit interviews found the support of the Twitter group at least somewhat useful. To explore the feasibility of eliminating in-person visits, in Study 3 (n=12), we delivered a 12-week lifestyle intervention almost entirely via Twitter by limiting the number of group visits to one, while using the same inclusion criteria as that used in Study 2. Participants lost, on average, 5.4 pounds (SD 6.4; range -14.2 to 3.9) or 3.0% (SD 3.1) of baseline weight, and 90% (9/10) completing exit interviews found the support of the Twitter group at least somewhat useful. Findings revealed that a private Twitter weight-loss group was both feasible and acceptable for many patients, particularly among regular users of social media. CONCLUSIONS: Future research should evaluate the efficacy and cost-effectiveness of online social network-delivered lifestyle interventions relative to traditional modalities.

Prevalence, Determinants, and Clinical Significance of Masked Hypertension in a Population-Based Sample of African Americans: The Jackson Heart Study.

BACKGROUND: The disproportionate rates of cardiovascular disease in African Americans may, in part, be due to suboptimal assessment of blood pressure (BP) with clinic BP measurements alone. To date, however, the prevalence of masked hypertension in African Americans has not been fully delineated. The purpose of this study was to evaluate masked hypertension prevalence in a large population-based sample of African Americans and examine its determinants and association with indices of target organ damage (TOD). METHODS: Clinic and 24-hour ambulatory BP monitoring were conducted in 972 African Americans enrolled in the Jackson Heart Study. Common carotid artery intima-media thickness, left ventricular mass index, and the urinary albumin:creatinine excretion ratio were evaluated as indices of TOD. RESULTS: Masked hypertension prevalence was 25.9% in the overall sample and 34.4% in participants with normal clinic BP. All indices of TOD were significantly higher in masked hypertensives compared to sustained normotensives and were similar between masked hypertensives and sustained hypertensives. Male gender, smoking, diabetes, and antihypertensive medication use were independent determinants of masked hypertension in multivariate analyses. CONCLUSIONS: In this population-based cohort of African Americans, approximately one-third of participants with presumably normal clinic BP had masked hypertension when BP was assessed in their daily environment. Masked hypertension was accompanied by a greater degree of TOD in this cohort.

The home environment and childhood obesity in low-income households: indirect effects via sleep duration and screen time.

BACKGROUND: Childhood obesity disproportionally affects children from low-income households. With the aim of informing interventions, this study examined pathways through which the physical and social home environment may promote childhood overweight/obesity in low-income households. METHODS: Data on health behaviors and the home environment were collected at home visits in low-income, urban households with either only normal weight (n = 48) or predominantly overweight/obese (n = 55) children aged 6-13 years. Research staff conducted comprehensive, in-person audits of the foods, media, and sports equipment in each household. Anthropometric measurements were collected, and children's physical activity was assessed through accelerometry. Caregivers and children jointly reported on child sleep duration, screen time, and dietary intake of foods previously implicated in childhood obesity risk. Path analysis was used to test direct and indirect associations between the home environment and child weight status via the health behaviors assessed. RESULTS: Sleep duration was the only health behavior associated with child weight status (OR = 0.45, 95% CI: 0.27, 0.77), with normal weight children sleeping 33.3 minutes/day longer on average than overweight/obese children. The best-fitting path model explained 26% of variance in child weight status, and included paths linking chaos in the home environment, lower caregiver screen time monitoring, inconsistent implementation of bedtime routines, and the presence of a television in children's bedrooms to childhood overweight/obesity through effects on screen time and sleep duration. CONCLUSIONS: This study adds to the existing literature by identifying aspects of the home environment that influence childhood weight status via indirect effects on screen time and sleep duration in children from low-income households. Pediatric weight management interventions for low-income households may be improved by targeting aspects of the physical and social home environment associated with sleep.