Effects of a behavioral intervention on physical activity, diet, and health-related quality of life in pregnant women with elevated weight: results of the HIPP randomized controlled trial.

BACKGROUND: Physical activity (PA), diet, and health-related quality of life (HRQOL) are related to maternal and infant health, but interventions to improve these outcomes are needed in diverse pregnant women with elevated weight. METHODS: Health In Pregnancy and Postpartum (HIPP) was a randomized controlled trial. Women who were pregnant (N=219, 44% African American, 56% white) with overweight or obesity but otherwise healthy were randomized to a behavioral intervention grounded in Social Cognitive Theory (n=112) or to standard care (n=107). The intervention group received an in-depth counseling session, a private Facebook group, and 10 content-based counseling calls with accompanying behavioral podcasts followed by weekly or biweekly counseling calls until delivery. The standard care group received monthly mailings and 10 podcasts focused on healthy pregnancy. PA (SenseWear armband), diet (ASA24), and HRQOL (SF-12) measures were obtained from blinded assessors at baseline (<16 weeks) and late pregnancy (32 weeks). Mixed model repeated measures regression models tested treatment (Group x Time) and within-group effects. We hypothesized that intervention participants would have higher levels of PA, a better-quality diet, and higher HRQOL than standard care participants. Exploratory analyses examined whether changes in outcomes over time differed according to whether participants had recommended, excessive, or inadequate weight gain. RESULTS: Treatment effects favored intervention participants for vegetable intake (d=0.40, p<0.05) and % whole grains (d=0.60, p<0.01). HRQOL mental component improved in both groups, but less in intervention than standard care participants (d=-0.33, p<0.05). Time effects demonstrated that total PA, steps/day, and HRQOL physical component declined significantly in both groups. Within-group effects showed that diet quality significantly improved in intervention participants. Moderate-intensity PA declined significantly in standard care participants, whereas light-intensity PA declined and sedentary behavior increased significantly in intervention participants. Finally, exploratory analyses showed that total PA and light PA increased whereas sedentary behavior decreased among those meeting guidelines for weight gain, with opposite patterns seen among those with excessive or inadequate weight gain. CONCLUSIONS: The intervention improved several dietary outcomes but had modest impacts on PA and HRQOL, underscoring the challenge of behavior change during pregnancy. TRIAL REGISTRATION: This trial was registered in ClinicalTrials.gov on 10/09/2014. NCT02260518.

Process evaluation methods and results from the Health in Pregnancy and Postpartum (HIPP) randomized controlled trial.

BACKGROUND: Excessive gestational weight gain has increased over time and is resistant to intervention, especially in women living with overweight or obesity. This study described the process evaluation methods and findings from a behavioral lifestyle intervention for African American and white women living with overweight and obesity that spanned pregnancy (≤ 16 weeks gestation) through 6 months postpartum. METHODS: The Health in Pregnancy and Postpartum (HIPP) study tested a theory-based behavioral intervention (vs. standard care) to help women (N = 219; 44% African American, 29.1 ± 4.8 years) living with overweight or obesity meet weight gain guidelines in pregnancy and lose weight in postpartum. Participants completed process evaluation surveys at 32 weeks gestation (n = 183) and 6 months postpartum (n = 168) regarding their perceptions of most and least helpful aspects of the intervention. A database tracked delivery and receipt of intervention components (in-depth counseling session, telephone calls, podcasts). Descriptive statistics are used to report fidelity, dose, and participants' perceptions. We also tested whether dose of behavioral intervention components was associated with gestational weight gain and 6-month postpartum weight retention with linear regression models controlling for baseline age and gestational weeks, receipt of Medicaid, race, parity, and marital status. A content analysis was used to code and analyze responses to open-ended survey questions. RESULTS: Over 90% of participants (both groups) would recommend the program to a friend. Implementation fidelity was moderately high and greater in pregnancy than postpartum for all intervention components. Dose received and participants' ratings of the in-depth counseling session and telephone calls were more favorable than podcasts. The Facebook group was not perceived to be very helpful, likely because of low participant interaction. Although podcasts were created to reinforce call topics, this redundancy was viewed negatively by some. More calls completed and more podcasts downloaded related to lower gestational weight gain (p < .05). CONCLUSION: Study findings underscore challenges in engaging this important but busy population, especially during the postpartum period. TRIAL REGISTRATION: The study was registered at clinicaltrials.gov (NCT02260518) on 10/09/2014. https://clinicaltrials.gov/ct2/show/NCT02260518 .

Income, Race and its Association with Obesogenic Behaviors of U.S. Children and Adolescents, NHANES 2003-2006.

OBJECTIVES: To describe the associations of income and race with obesogenic behaviors and % body fat among a large sample of U.S. children and adolescents. DESIGN: Data were obtained from the 2003-2004 and 2005-2006 National Health and Nutritional Examination Survey. Multiple linear regression models and interactions were used to examine the associations of moderate-to-vigorous physical activity (MVPA), sedentary time, diet quality, and screen-time with income-to-poverty ratio and race. Separate stratified analyses explored associations among individual obesogenic behaviors within race and income groups. RESULTS: This study included children and adolescents (n = 3551, mean = 13.1 years, SD = 3.9 years) who were 37% Hispanic, 27% White, and 35% Black. Overall, Hispanic children/adolescents had significantly higher levels of adiposity (3.6, 95 CI = 0.9, 6.3) than white children and adolescents. Medium-income children and adolescents engaged in less MVPA (- 3.3 min, 95 CI = - 5.1, - 1.5), had poorer diet quality (- 1.1, 95 CI = - 1.9, - 0.2), and used screens less (- 33.9 min, 95 CI = - 45.4, - 22.4) than children and adolescents from low-income households. High-income children and adolescents also engaged in less MVPA (- 3.1 min, 95 CI = - 5.5, - 0.7) and used screens less (- 62.9 min, 95 CI = - 78.3, - 47.4) than children and adolescents from low-income households. However, there were significant race/ethnicity-by-income interactions for high-income Hispanic children and adolescents with diet quality (- 3.5 HEI-2010 score, 95 CI = - 6.6, - 0.4) and screen time (66.9 min, 95 CI = 24.7, 109.0). There was also a significant race/ethnicity-by-income interaction for the screen-time of Black children and adolescents from medium (33.8 min, 95% CI 0.2, 67.3) and high (75.8 min, 95% CI 34.7, 117.0) income households. CONCLUSIONS: There appears to be a complex relationship that varies by race/ethnicity between income, obesogenic behaviors, and adiposity levels among children and adolescents. More work is needed to identify the behavioral mechanisms that are driving disparate rates of overweight and obesity among minority children and those from low-income households.

Non-communicable diseases and preventive health behaviors: a comparison of Hispanics nationally and those living along the US-Mexico border.

BACKGROUND: Non-communicable diseases (NCDs) are rising among US Hispanics, but few studies have examined the preventive health behaviors for these NCDs among Hispanics. This study compared the preventive health behaviors of smoke-free living, physical activity, fruit and vegetable consumption, and avoidance of heavy alcohol use in Hispanics in the United States and Hispanics living along the US-Mexico border. METHODS: Two weighted data sets with information on Hispanic populations were analyzed: 1) the national Behavioral Risk Factor Surveillance Survey (n = 29,942) from 2009; and 2) the Cameron County Hispanic Cohort (n = 1,439) recruited from the US-Mexico border between 2008-2011. To compare the preventive health behaviors of the samples, within a generalized estimating equation framework, weighted univariate and multivariate logistic regression analyses were conducted controlling for age, educational attainment, employment, language, and insurance status. Statistical tests were two-sided with a significance level set at 0.05. RESULTS: Both samples reported low engagement in preventive behaviors. However, Hispanic males and females from the US-Mexico border were significantly less likely than the national sample to meet physical activity and fruit and vegetable consumption guidelines. Also, Hispanic males from the US-Mexico border were more likely to engage in heavy alcohol use. CONCLUSION: The lack of preventive health behaviors among Hispanics living along the US-Mexico border presents a dire prospect for NCD control in the region. Multipronged approaches to address multiple behaviors should be considered.

Associations of maternal stress and/or depressive symptoms with diet quality during pregnancy: a narrative review.

BACKGROUND: Pregnancy can be a stressful time for many women; however, it is unclear if higher stress and depressive symptoms are associated with poorer diet quality during pregnancy. OBJECTIVE: The aims for this narrative review were to (1) synthesize findings of original, peer-reviewed studies that examined associations of stress and/or depressive symptoms with diet quality during pregnancy; (2) review the measurement tools used to assess stress, depressive symptoms, and diet quality; (3) identify current gaps in the extant literature; and (4) offer recommendations for future research. METHODS: A search strategy was used to identify peer-reviewed manuscripts published between January 1997 and October 2018, using the following databases: PubMed, CINAHL Complete, PsycINFO, Academic Search Complete, and Psychology & Behavioral Sciences Collection. The search was updated December 2019. Two reviewers independently assessed title, abstract, and full-text of the studies that met the inclusion criteria. Data were extracted and a quality assessment was conducted. RESULTS: Twenty-seven observational studies were identified in this review (21 cross-sectional and 6 longitudinal). In 22 studies, higher stress and/or depressive symptoms were associated with poorer diet quality or unhealthy dietary patterns; 5 studies found no association. Findings are mixed and inconclusive regarding the relationship among stress, depressive symptoms, and food groups related to diet quality and frequency of fast-food consumption. CONCLUSIONS: The current data suggest stress and depressive symptoms may be a barrier to proper diet quality during pregnancy; however, variability in the assessment tools, timing of assessments, and use of covariates likely contribute to the inconsistency in study findings. Gaps in the literature include limited use of longitudinal study designs, limited use of comprehensive diet-quality indices, underrepresentation of minority women, and lack of multilevel theoretical frameworks. Studies should address these factors to better assess associations of stress and/or depressive symptoms with diet quality during pregnancy.

Stress and Depressive Symptoms Are Not Associated with Overall Diet Quality, But Are Associated with Aspects of Diet Quality in Pregnant Women in South Carolina.

BACKGROUND: Poor mental health may hinder diet quality in pregnancy. OBJECTIVE: This study 1) examined whether stress and depressive symptoms are associated with diet quality (via Healthy Eating Index [HEI] 2015 total scores and dietary intake of food groups/nutrients that align with HEI-2015 components) and 2) tested race as a moderator in the relationship between mental health and diet quality. DESIGN: This was a cross-sectional analysis of baseline data from a randomized controlled trial collected January 2015 through January 2019 in Columbia, South Carolina. Trained staff administered demographic and psychosocial questionnaires and conducted anthropometric measures. Participants completed two 24-hour dietary recalls, which were self-administered (one on-site, one at home). PARTICIPANTS: The Health in Pregnancy and Postpartum study was a randomized controlled trial targeting excessive gestational weight gain among pregnant women with overweight/obesity (N = 228). MAIN OUTCOME MEASURES: The HEI-2015 total scores and food groups/nutrients that align with HEI-2015 were calculated. STATISTICAL ANALYSES PERFORMED: Multiple linear regression models were used to estimate the relationship between mental health and HEI-2015 total scores and dietary intake of food groups or nutrients that align with HEI-2015 components. Multiplicative interaction terms of stress or depressive symptoms with race were used to determine moderation. RESULTS: Participants' diet quality was suboptimal (M = 52.0 ± 11.7; range, 27-85). Stress was negatively associated with HEI-2015 total scores (crude but not adjusted model). Stress scores were positively associated with consumption of dairy, refined grains, and added sugars and negatively associated with total protein foods. Depressive symptoms were positively associated with consumption of dairy, refined grains, and saturated fats. Race was not a moderator. CONCLUSIONS: Diet quality was poor overall, but stress and depressive symptoms were not associated with HEI-2015 total scores in adjusted models. Excluding dairy, stress and depressive symptoms were associated with the consumption of food groups or nutrients related to worse diet quality. These relationships should be examined longitudinally to help establish causality and inform future interventions.

Healthy Food Density is Not Associated With Diet Quality Among Pregnant Women With Overweight/Obesity in South Carolina.

OBJECTIVE: Examine the association and moderating effect of residential location (urban/rural) on the relationship between neighborhood healthy food density and diet quality. DESIGN: Cross-sectional analysis of baseline data from the Health in Pregnancy and Postpartum study, a randomized trial designed to prevent excessive gestational weight gain. PARTICIPANTS: Pregnant women in South Carolina with prepregnancy overweight/obesity (n = 228). MAIN OUTCOME MEASURES: Healthy Eating Index-2015 (HEI) was used to measure diet quality from 2 24-hour dietary recalls. The HEI total scores and 11 binary HEI components (those that met the standard for maximum component score vs those that did not) were calculated as dependent variables. ANALYSIS: Multiple linear and logistic regression models were used to examine the association between healthy food density and HEI total scores and meeting the standards for maximum component scores. Healthy food density × residential location tested for moderation. P < 0.05 indicated significance. RESULTS: Participants' diet quality was suboptimal (mean, 52.0; SD, 11.7; range, 27-85). Healthy food density was not significantly related to HEI total scores or components, and residential location was not a moderator. CONCLUSIONS AND IMPLICATIONS: Diet quality was suboptimal, and there was no relationship between healthy food density and diet quality among Health in Pregnancy and Postpartum study participants. These data support examining behavioral factors that could influence diet quality.

The role of self-efficacy and information processing in weight loss during an mHealth behavioral intervention.

Self-efficacy (SE) and information processing (IP) may be important constructs to target when designing mHealth interventions for weight loss. The goal of this study was to examine the relationship between SE and IP with weight loss at six-months as part of the Dietary Interventions Examining Tracking with mobile study, a six-month randomized trial with content delivered remotely via twice-weekly podcasts. Participants were randomized to self-monitor their diet with either a mobile app (n = 42) or wearable Bite Counter device (n = 39). SE was assessed using the Weight Efficacy Life-Style Questionnaire and the IP variables assessed included user control, cognitive load, novelty, elaboration. Regression analysis examined the relationship between weight loss, SE change & IP at six months. Results indicate that elaboration was the strongest predictor of weight loss (ß =-0.423, P = 0.011) among all SE & IP variables and that for every point increase in elaboration, participants lost 0.34 kg body weight.

Defining Adherence to Mobile Dietary Self-Monitoring and Assessing Tracking Over Time: Tracking at Least Two Eating Occasions per Day Is Best Marker of Adherence within Two Different Mobile Health Randomized Weight Loss Interventions.

BACKGROUND: Mobile dietary self-monitoring methods allow for objective assessment of adherence to self-monitoring; however, the best way to define self-monitoring adherence is not known. OBJECTIVE: The objective was to identify the best criteria for defining adherence to dietary self-monitoring with mobile devices when predicting weight loss. DESIGN: This was a secondary data analysis from two 6-month randomized trials: Dietary Intervention to Enhance Tracking with Mobile Devices (n=42 calorie tracking app or n=39 wearable Bite Counter device) and Self-Monitoring Assessment in Real Time (n=20 kcal tracking app or n=23 photo meal app). PARTICIPANTS/SETTING: Adults (n=124; mean body mass index=34.7±5.6) participated in one of two remotely delivered weight-loss interventions at a southeastern university between 2015 and 2017. INTERVENTION: All participants received the same behavioral weight loss information via twice-weekly podcasts. Participants were randomly assigned to a specific diet tracking method. MAIN OUTCOME MEASURES: Seven methods of tracking adherence to self-monitoring (eg, number of days tracked, and number of eating occasions tracked) were examined, as was weight loss at 6 months. STATISTICAL ANALYSES PERFORMED: Linear regression models estimated the strength of association (R2) between each method of tracking adherence and weight loss, adjusting for age and sex. RESULTS: Among all study completers combined (N=91), adherence defined as the overall number of days participants tracked at least two eating occasions explained the most variance in weight loss at 6 months (R2=0.27; P<0.001). Self-monitoring declined over time; all examined adherence methods had fewer than half the sample still tracking after Week 10. CONCLUSIONS: Using the total number of days at least two eating occasions are tracked using a mobile self-monitoring method may be the best way to assess self-monitoring adherence during weight loss interventions. This study shows that self-monitoring rates decline quickly and elucidates potential times for early interventions to stop the reductions in self-monitoring.

A randomized controlled trial to prevent excessive gestational weight gain and promote postpartum weight loss in overweight and obese women: Health In Pregnancy and Postpartum (HIPP).

BACKGROUND: Interventions to prevent excessive gestational weight gain and promote postpartum weight loss have yielded modest results, particularly in overweight and obese women. OBJECTIVES: To examine the impact of a theory-based lifestyle intervention on gestational weight gain, postpartum weight loss, and related maternal and child outcomes and to examine race differences in these outcomes. DESIGN: A randomized controlled trial (target N=400; 200 intervention, 200 standard care; 200 African American, 200 white). METHODS: Overweight and obese African American and white women ≤16weeks gestation are recruited from obstetrics and gynecology clinics in South Carolina. Intervention participants receive two in-depth counseling sessions (early pregnancy and postpartum), telephone counseling, behavioral podcasts, and social media support that target weight self-monitoring and increasing physical activity and healthy dietary behavior practices, guided by Social Cognitive Theory. Standard care participants receive monthly mailings and a matched number of podcasts on non-weight related topics. All intervention activities last from ≤18weeks gestation to 6months after delivery. Gestational weight gain is the primary outcome. Secondary outcomes are meeting gestational weight gain guidelines (inadequate, adequate, excessive), weekly rate of gestational weight gain, postpartum weight retention, physical activity and dietary behaviors, health-related quality of life, and offspring adiposity. Participants are assessed at baseline (≤16weeks gestation), 32weeks gestation, and 6 and 12months postpartum, and offspring are assessed at 6 and 12months. SUMMARY: HIPP is an innovative study that addresses significant gaps in the literature. Primary outcome results are expected in 2019.

Byte by Bite: Use of a mobile Bite Counter and weekly behavioral challenges to promote weight loss.

The goal of this study was to examine the usability and feasibility of the mobile Bite Counter (a watch-like device that detects when a user consumes food or beverage) and the impact of weekly behavioral challenges on diet and physical activity outcomes. Overweight (mean BMI 31.1±4.9 kg/m2) adults (n=12) were recruited to participate in a four-week study to test both the usability and feasibility of using the device as part of a behavioral weight loss intervention. Participants were instructed to self-monitor number of bites/day using the Bite Counter, attend weekly group sessions, and listen to weekly podcasts. Participants were given weekly challenges: use a daily bite limit goal (wk1), turn off Bite Counter when fruits/vegetables are consumed (wk2), self-monitor kilocalories vs. bites (wk3), and receive a 10 bites/day bonus for every 30 minutes of exercise (wk4). Participants lost a mean of -1.2±1.3 kg. Only the wk3 challenge produced significant differences in kcal change (wk3 1302±120 kcal/day vs. baseline 2042±302 kcal/d, P<0.05). Bite Counter use was significantly correlated with weight loss (r= -0.58, P<0.05). Future studies should examine the use of the Bite Counter and impact of behavioral challenges over a longer period of time in a controlled study.

The Dietary Intervention to Enhance Tracking with Mobile Devices (DIET Mobile) Study: A 6-Month Randomized Weight Loss Trial.

OBJECTIVE: To examine the use of two different mobile dietary self-monitoring methods for weight loss. METHODS: Adults with overweight (n = 81; mean BMI 34.7 ± 5.6 kg/m2 ) were randomized to self-monitor their diet with a mobile app (App, n = 42) or wearable Bite Counter device (Bite, n = 39). Both groups received the same behavioral weight loss information via twice-weekly podcasts. Weight, physical activity (International Physical Activity Questionnaire), and energy intake (two dietary recalls) were assessed at 0, 3, and 6 months. RESULTS: At 6 months, 75% of participants completed the trial. The App group lost significantly more weight (-6.8 ± 0.8 kg) than the Bite group (-3.0 ± 0.8 kg; group × time interaction: P < 0.001). Changes in energy intake (kcal/d) (-621 ± 157 App, -456 ± 167 Bite; P = 0.47) or number of days diet was tracked (90.7 ± 9.1 App, 68.4 ± 9.8 Bite; P = 0.09) did not differ between groups, but the Bite group had significant increases in physical activity metabolic equivalents (+2015.4 ± 684.6 min/wk; P = 0.02) compared to little change in the App group (-136.5 ± 630.6; P = 0.02). Total weight loss was significantly correlated with number of podcasts downloaded (r = -0.33, P < 0.01) and number of days diet was tracked (r = -0.33, P < 0.01). CONCLUSIONS: While frequency of diet tracking was similar between the App and Bite groups, there was greater weight loss observed in the App group.