Melissa H. Goodman

Delta Healthy Sprouts: A randomized comparative effectiveness trial to promote maternal weight control and reduce childhood obesity in the Mississippi Delta

INTRODUCTION Excessive and inadequate gestational weight gain can complicate a womans pregnancy and put her and her child at risk for poor delivery and birth outcomes. Further, feeding and activity habits established early in life can significantly impact the development of childhood obesity. METHODS The on-going Delta Healthy Sprouts Project is a randomized, controlled, comparative trial testing the efficacy of two Maternal, Infant, and Early Childhood Home Visiting programs on weight status and health behaviors of 150 mothers and their infants residing in the rural Mississippi Delta region of the United States. Women are enrolled in their second trimester of pregnancy and randomized to one of two treatment arms. The control arm curriculum is based on Parents as Teachers, an evidence based approach to increase parental knowledge of child development and improve parenting practices. The experimental arm, labeled Parents as Teachers Enhanced, builds upon the control curriculum by including culturally tailored nutrition and physical activity components specifically designed for the gestational and postnatal periods. We hypothesize that, as compared to the control arm, the experimental arm will be more effective in preventing inappropriate gestational weight gain, reducing postnatal weight retention, and decreasing infant obesity rates. We also will evaluate mother and child dietary and physical activity outcomes, breastfeeding initiation and continuation, and child feeding practices. CONCLUSION The Delta Healthy Sprouts Project tests a novel, combined approach to maternal weight management and childhood obesity prevention in pregnant women and their children at high risk for obesity and chronic disease.

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.

Diet Quality and Physical Activity Outcome Improvements Resulting From a Church-Based Diet and Supervised Physical Activity Intervention for Rural, Southern, African American Adults Delta Body and Soul III

We assessed the effects of a 6-month, church-based, diet and supervised physical activity intervention, conducted between 2011 and 2012, on improving diet quality and increasing physical activity of Southern, African American adults. Using a quasi-experimental design, eight self-selected, eligible churches were assigned to intervention or control. Assessments included dietary, physical activity, anthropometric, and clinical measures. Mixed model regression analysis and McNemar’s test were used to determine if within and between group differences were significant. Cohen’s d effect sizes for selected outcomes also were computed and compared with an earlier, lower dose intervention. Retention rates were 84% (102/122) for control and 76% (219/287) for intervention participants. Diet quality components, including fruits, vegetables, discretionary calories, and total quality, improved significantly in the intervention group. Strength/flexibility physical activity also increased in the intervention group, while both aerobic and strength/flexibility physical activity significantly decreased in the control group. Effect sizes for selected health outcomes were larger in the current intervention as compared to an earlier, less intense iteration of the study. Results suggest that more frequent education sessions as well as supervised group physical activity may be key components to increasing the efficacy of behavioral lifestyle interventions in rural, Southern, African American adults.

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.

Psychosocial constructs were not mediators of intervention effects for dietary and physical activity outcomes in a church-based lifestyle intervention: Delta Body and Soul III.

OBJECTIVE Evaluating an interventions theoretical basis can inform design modifications to produce more effective interventions. Hence the present studys purpose was to determine if effects from a multicomponent lifestyle intervention were mediated by changes in the psychosocial constructs decisional balance, self-efficacy and social support. DESIGN Delta Body and Soul III, conducted from August 2011 to May 2012, was a 6-month, church-based, lifestyle intervention designed to improve diet quality and increase physical activity. Primary outcomes, diet quality and aerobic and strength/flexibility physical activity, as well as psychosocial constructs, were assessed via self-report, interviewer-administered surveys at baseline and post intervention. Mediation analyses were conducted using ordinary least squares (continuous outcomes) and maximum likelihood logistic (dichotomous outcomes) regression path analysis. SETTING Churches (five intervention and three control) were recruited from four counties in the Lower Mississippi Delta region of the USA. SUBJECTS Rural, Southern, primarily African-American adults (n 321). RESULTS Based upon results from the multiple mediation models, there was no evidence that treatment (intervention v. control) indirectly influenced changes in diet quality or physical activity through its effects on decisional balance, self-efficacy and social support. However, there was evidence for direct effects of social support for exercise on physical activity and of self-efficacy for sugar-sweetened beverages on diet quality. CONCLUSIONS Results do not support the hypothesis that the psychosocial constructs decisional balance, self-efficacy and social support were the theoretical mechanisms by which the Delta Body and Soul III intervention influenced changes in diet quality and physical activity.

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

BackgroundDespite 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.MethodsEighty-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.ResultsBreastfeeding 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.ConclusionsOur 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 Registrationclinicaltrials.gov NCT01746394. Registered 5 December 2012.

Engagement indicators predict health changes in a lifestyle intervention.

OBJECTIVE To evaluate the utility of several participant engagement indicators for predicting health changes in a church-based lifestyle intervention shown effective for improving dietary, physical activity, and clinical outcomes. METHODS Descriptive indicators were constructed using 2 participant engagement measures - education session attendance (EDA) and exercise class attendance (EXA) - separately and combined. Relationships of 6 engagement indicators to health outcomes were tested using generalized linear mixed models. RESULTS EDA predicted 5 dietary and 1 clinical outcome, whereas EXA predicted one physical activity and one clinical outcome. The combined indicator predicted the same 7 outcomes. CONCLUSION Use of single engagement indicators specific to each intervention component is advocated for predicting relevant health outcome.

Infant growth outcomes from birth to 12 months of age: findings from the Delta Healthy Sprouts randomized comparative impact trial: Infant growth from birth to 12 months

Multicomponent lifestyle modification interventions designed for gestational and early postnatal periods may be key to preventing obesity in children. The primary objective of the study was to determine if infant growth outcomes differed between treatment arms of an 18‐month, maternal, infant and early childhood home visiting project.

No Improvements in Postnatal Dietary Outcomes Were Observed in a Two-Arm, Randomized, Controlled, Comparative Impact Trial among Rural, Southern, African-American Women

BACKGROUND Suboptimal diet quality, prevalent among postpartum women, is troubling for mothers and their children because positive relationships between maternal and child diet quality exist. OBJECTIVE The primary objective was to determine whether postnatal diet quality scores of participants in the two treatment arms differed or changed over time. DESIGN Delta Healthy Sprouts was a two-arm, randomized, controlled, comparative impact trial. PARTICIPANTS AND SETTING Pregnant women at least 18 years of age, less than 19 weeks pregnant, and residing in three Mississippi counties were recruited between March 2013 and December 2014. Postnatal data was collected from 54 participants between September 2013 and May 2016. The postnatal attrition rates were 17% and 13% for the control and experimental arms. INTERVENTION The control arm received the Parents as Teachers curriculum, and the experimental arm received a nutrition- and physical activity-enhanced Parents as Teachers curriculum. MAIN OUTCOME MEASURES Multiple-pass 24-hour dietary recalls were collected from participants at the postnatal month 1, 4, 6, 8, and 12 visits. Healthy Eating Index-2010 was used to calculate diet quality. STATISTICAL ANALYSIS PERFORMED Linear mixed models were used to test for treatment, time, and treatment by time (interaction) effects on postnatal dietary outcomes. RESULTS Control arm mean (95% confidence limits) total Healthy Eating Index-2010 scores were 36.8 (range=32.5 to 41.1), 36.5 (range=31.9 to 41.1), 40.2 (range=35.7 to 44.8), 39.3 (range=34.7 to 43.9), and 36.4 (range=31.8 to 41.0) at postnatal months 1, 4, 6, 8, and 12, respectively. Corresponding experimental arm scores were 42.3 (range=37.5 to 47.0), 41.6 (range=36.3 to 46.9), 40.2 (range=34.8 to 45.7), 45.8 (range=40.5 to 51.1), and 37.6 (range=32.6 to 42.7), respectively. Experimental scores were significantly higher than control scores across time. No other effects were significant. CONCLUSIONS Neither the standard Parents as Teachers curriculum nor the enhanced Parents as Teachers curriculum was effective at improving the poor diet quality of this cohort of rural, Southern, African-American women during the 12 months following the birth of their infant.

Feasibility of Online Nutrition Education in the Workplace: Working Toward Healthy Lifestyles

Objective: Determination of feasibility of online nutrition education in the federal workplace. Design: Pretest–posttest pilot study with data collection occurring from September to December, 2016. Setting: Two US Department of Agriculture workplaces. Participants: Convenience sample of 26 federal government employees. Posttest response rate was 85% (22 of 26 employees). Intervention: A 12‐week online nutrition education program designed and taught by registered dietitian nutritionists. Variables Measured: Program component satisfaction, use, and understanding ratings and clinical measures including body composition, blood pressure, and skin carotenoid level (biomarker for fruit and vegetable intake). Analysis: Paired t tests to determine whether significant changes occurred after the intervention. Results: Mean number of class videos viewed and program components used were 7 and 5 (out of 12 for both). Mean program component ratings ranged from 4.0 to 4.7 (n = 12, maximum score of 5) for the survey items motivated/helped me to eat healthier. Statistically significant decreases were observed in body mass index, percent body fat, and visceral fat level. Conclusions and Implications: Online nutrition education in the federal workplace is feasible for some employees as evidenced by the program components’ high satisfaction and understanding ratings and high retention rate. Limited evidence was apparent for the interventions positive impact on health outcomes.