Rebecca J. Namenek Brouwer

Active Mothers Postpartum A Randomized Controlled Weight-Loss Intervention Trial

BACKGROUND Pregnancy may contribute to overweight and obesity. PURPOSE The primary objective of Active Mothers Postpartum was to promote a reduction in BMI through 24-months postpartum via sustainable lifestyle changes. DESIGN Behavioral intervention RCT to enhance postpartum weight loss. SETTING/PARTICIPANTS A total of 450 overweight or obese women, enrolled 6-weeks postpartum, were recruited through obstetrics clinics and community posters in the Durham NC area. INTERVENTION Intervention participants were offered eight healthy-eating classes, ten physical-activity classes, and six telephone-counseling sessions over 9 months. MAIN OUTCOME MEASURES Changes from baseline (6-weeks postpartum) to 1-month post-intervention (12-months postpartum) in: (1) diet (caloric intake, calories from fat, intake of certain foods); (2) physical activity (self-reported physical activity, television time); and (3) weight (collected 2004-2007, analyzed 2007-2008). RESULTS Mean weight loss was 0.90 kg (+/-5.1 kg) in the intervention group and 0.36 kg (+/-4.9 kg) in the control group; this difference was not significant. There were also no significant group differences in improvement of diet or increased physical activity. In secondary analyses, there was a positive bivariate relationship between classes attended and weight loss (p=0.01). CONCLUSIONS There were no significant differences among the arms in diet, physical activity, or weight change. Home-based interventions via mail, telephone, or Internet/e-mail may be more feasible and successful in this population. The postpartum period is an important phase in womens lives with regard to weight retention, but engaging them during this busy period remains a challenge. TRIAL REGISTRATION NCT00212251.

Diet quality and weight change among overweight and obese postpartum women enrolled in a behavioral intervention program.

BACKGROUND Postpartum weight retention is a risk factor for long-term weight gain. Encouraging new mothers to consume a healthy diet may result in weight loss. OBJECTIVE To assess predictors of diet quality during the early postpartum period; to determine whether diet quality, energy intake, and lactation status predicted weight change from 5 to 15 months postpartum; and to determine whether an intervention improved diet quality, reduced energy intake, and achieved greater weight loss compared with usual care. DESIGN Randomized clinical trial (KAN-DO: Kids and Adults Now-Defeat Obesity), a family- and home-based, 10-month, behavioral intervention to prevent childhood obesity, with secondary aims to improve diet and physical activity habits of mothers to promote postpartum weight loss. PARTICIPANTS Overweight/obese, postpartum women (n=400), recruited from 14 counties in the Piedmont region of North Carolina. INTERVENTION Eight education kits, each mailed monthly; motivational counseling; and one group class. METHODS Anthropometric measurements and 24-hour dietary recalls collected at baseline (approximately 5 months postpartum) and follow-up (approximately 10 months later). Diet quality was determined using the Healthy Eating Index-2005 (HEI-2005). STATISTICAL ANALYSES Descriptive statistics, χ(2), analysis of variance, bi- and multivariate analyses were used. RESULTS At baseline, mothers consumed a low-quality diet (HEI-2005 score=64.4 ± 11.4). Breastfeeding and income were positive, significant predictors of diet quality, whereas body mass index was a negative predictor. Diet quality did not predict weight change. However, total energy intake, not working outside of the home, and breastfeeding duration/intensity were negative predictors of weight loss. There were no significant differences in changes in diet quality, decreases in energy intake, or weight loss between the intervention (2.3 ± 5.4 kg) and control (1.5 ± 4.7 kg) arms. CONCLUSIONS The family-based intervention did not promote postpartum weight loss. Reducing energy intake, rather than improving diet quality, should be the focus of weight-loss interventions for overweight/obese postpartum women.

Active Mothers Postpartum (AMP): Rationale, Design, and Baseline Characteristics

BACKGROUND Pregnancy and the postpartum period have been suggested as important contributors to overweight and obesity among women. This paper presents the design, rationale, and baseline participant characteristics of a randomized controlled intervention trial to enhance weight loss in postpartum women who entered pregnancy overweight or obese. METHODS Active Mothers Postpartum (AMP) is based on the rationale that the birth of a child can be a teachable moment. AMPs primary objectives are to promote and sustain a reduction in body mass index (BMI) up to 2 years postpartum via changes in diet and exercise behavior, with a secondary aim to assess racial differences in these outcomes. Women in the intervention arm participate in ten physical activity group sessions, eight healthy eating classes, and six telephone counseling sessions over a 9-month period. They also receive motivational tools, including a workbook with recipes and exercises, a pedometer, and a sport stroller. RESULTS Four hundred fifty women aged > or =18 (mean 30.9), with a BMI > or = 25 kg/m(2) (mean 33.0) at baseline (6 weeks postpartum) were enrolled; 45% of the final sample are black and 53% are white. Baseline characteristics by study arm and by race are presented. CONCLUSIONS Our intervention is designed to be disseminated broadly to benefit the public health. Behavior change interventions based on principles of social cognitive theory, stage of readiness, and other models that coincide with a teachable moment, such as the birth of a child, could be important motivators for postpartum weight loss.

The effect of the home environment on physical activity and dietary intake in preschool children.

Background:The effects of the home environment on child health behaviors related to obesity are unclear.Purpose:To examine the role of the home physical activity (PA) and food environment on corresponding outcomes in young children, and assess maternal education/work status as a moderator.Methods:Overweight or obese mothers reported on the home PA and food environment (accessibility, role modeling and parental policies). Outcomes included child moderate–vigorous PA (MVPA) and sedentary time derived from accelerometer data and two dietary factors (‘junk’ and healthy food intake scores) based on factor analysis of mother-reported food intake. Linear regression models assessed the net effect (controlling for child demographics, study arm, supplemental time point, maternal education/work status, child body mass index and accelerometer wear time (for PA outcomes)) of the home environment on the outcomes and moderation by maternal education/work status. Data were collected in North Carolina from 2007 to 2011.Results:Parental policies supporting PA increased MVPA time, and limiting access to unhealthy foods increased the healthy food intake score. Role modeling of healthy eating behaviors increased the healthy food intake score among children of mothers with no college education. Among children of mothers with no college education and not working, limiting access to unhealthy foods and role modeling reduced ‘junk’ food intake scores whereas parental policies supporting family meals increased ‘junk’ food intake scores.Conclusions:To promote MVPA, parental policies supporting child PA are warranted. Limited access to unhealthy foods and role modeling of healthy eating may improve the quality of the child’s food intake.

Adherence to nicotine replacement therapy among pregnant smokers.

INTRODUCTION This secondary analysis examined the association between adherence to nicotine replacement therapy (NRT) and smoking cessation among pregnant smokers enrolled in Baby Steps, an open-label randomized controlled trial testing cognitive-behavioral therapy (CBT) versus CBT plus NRT. METHOD The analysis included only women who received NRT for whom we had complete data (N = 104). Data came from daily calendars created from recordings of counseling sessions and from telephone surveys at baseline and 38 weeks gestation. RESULTS Overall, 29% of the 104 women used NRT for the recommended 6 weeks and 41% used NRT as directed in the first 48 hr after a quit attempt. Ordinal logistic regression modeling indicated that using NRT as directed in the first 48 hr and having made a previous quit attempt were the strongest predictors of longer NRT use. Univariate analyses suggested that primigravid women and women who used NRT longer were more likely to report quitting at 38 weeks gestation. DISCUSSION Findings indicated that adherence to NRT is low among pregnant smokers, but adherence was a predictor of cessation. Future trials should emphasize adherence, particularly more days on NRT, to promote cessation during pregnancy.

Emergence of depression during early abstinence in depressed and non-depressed women smokers.

Abstract The emergence of depression early in a quit attempt and its relationship to ability to maintain abstinence were studied in 99 depressed and non-depressed women smokers. Participants rated withdrawal symptomatology during a baseline week and the first two weeks of a quit attempt, during which they used a 21-mg nicotine patch and received behavioral counseling. Depressed women experienced greater difficulty maintaining early abstinence than non-depressed women. They were significantly more likely to smoke on the first day of abstinence and smoked marginally more days during the first week. Among participants who relapsed during the first two weeks, latency to relapse was significantly shorter for depressed women. Although craving and all withdrawal symptoms except insomnia showed significant increases over baseline, only depression showed significant group differences, with trend analyses suggesting that depression asymptotes in non-depressed women after the first week but continues increasing in depressed women. Larger increases in depression on the first day of abstinence were associated with earlier lapse. Because depression is relatively infrequent as a withdrawal symptom, it may not be a “true” withdrawal symptom except in depressed people. Identification of depressed smokers and anticipation of their increased need for support during this period may help to counteract the “first-day effect” and difficulties during early abstinence.

Weight concerns in women smokers during pregnancy and postpartum.

When women smokers become pregnant, they are asked to control weight gain and at the same time to relinquish an addictive drug with weight suppressing effects. For women with serious body image concerns or a history of unhealthful eating patterns, smoking cessation may be particularly problematic. To investigate the relationship of weight concerns with smoking and weight gain during pregnancy and postpartum weight loss strategies, we conducted a retrospective study of women who had given birth to their first child within the past 10 years and were smokers when they became pregnant. We observed that women smokers with high weight and body image concerns (HC) gained significantly more weight during pregnancy-in amounts that far exceeded maximum recommended weight gain-than did women with low concerns (LC). HC were more likely to adopt smoking as a weight-control strategy and to be receptive to multiple weight-control strategies. Although they lost significantly more weight in the first month postpartum than did LC, they had also gained significantly more during pregnancy; the net result was that weight loss as a percentage of weight gained did not differ significantly between groups. HC were significantly less likely to experience food cravings in the first trimester and marginally less likely to vomit than LC. We conclude that early identification of high-risk women, coordination of prenatal care with smoking cessation counseling, and development of effective relapse prevention strategies that specifically address weight issues both during and after pregnancy will be needed if efforts to reduce smoking during pregnancy and postpartum are to be optimized.

Primary Care Physicians' Discussions of Weight-Related Topics with Overweight and Obese Adolescents: Results from the Teen CHAT Pilot Study

Physicians should counsel overweight adolescents about nutrition and exercise. We audio recorded 30 physician-adolescent encounters. Female, older, normal-weight physicians and pediatricians were more Motivational Interviewing (MI) adherent. When physicians used MI skills, patients increased exercise, lost weight, and reduced screen time. Physicians should use MI techniques to help adolescents change.

Race differences in weight concerns among women smokers: Results from two independent samples

To investigate attitudes about weight as they interact with smoking in African American women, we analyzed data from two independent samples of white and African American women smokers--one assembled via a national random-digit-dialing survey, the other consisting of candidates for enrollment in local studies. Findings for the two samples were remarkably consistent. African American women were significantly heavier and significantly more likely to have a self-reported BMI > or = 27. Although the preferred weight for African American women was significantly higher than for white women, the percentage by which they exceeded their preferred body weight did not differ significantly between groups, and the difference between actual and preferred weights was actually greater for African American women. African American women were more likely to be satisfied with their body shape and were significantly less likely to exercise to control weight. They did not differ significantly on binge-eating or dieting. African American women were more likely than white women to be unwilling to gain any weight upon quitting smoking but did not differ significantly on any other smoking-related weight concerns. Our results suggest that weight concerns, though differently conceptualized, may motivate African American women as powerfully as white women. They strongly suggest that race differences need to be considered in designing optimal smoking cessation interventions for weight-concerned women smokers. To accomplish this goal, efforts to identify a vocabulary for the expression of weight concerns in African American women will be needed, as will attention to ways to avoid exacerbating obesity and to encourage exercise.

Comparison of Dietary Intake of Overweight Postpartum Mothers Practicing Breastfeeding or Formula Feeding

BACKGROUND Weight gain in the postpartum period is a risk factor for long-term obesity. Investigations of dietary intake among lactating and nonlactating overweight women might identify nutritional concerns specific to this population. OBJECTIVE To compare nutrient, meal, and snack intakes, food-group servings and prevalence of dieting among fully breastfeeding (BF), mixed breast and formula feeding (MF), and formula feeding (FF) overweight and obese women. The second aim was to compare nutrient intakes and food-group servings to the Dietary Reference Intake and MyPyramid recommendations, respectively. DESIGN Data were collected from September 2004 through April 2006 in Durham, NC. Infant feeding practices and dietary information were collected on 450 women between 6 and 9 weeks postpartum. Two 24-hour dietary recalls were completed by phone, using Nutrition Data Systems for Research. Analysis of covariance was used to compare infant feeding groups in dietary quality (nutrient intake per 1,000 kcal) and food-group servings, controlling for prepregnancy body mass index, race, age, education, income, and marital status. χ² analysis was performed to determine differences in meal and snack intake and dieting among infant feeding groups. RESULTS BF women consumed more energy (2,107 ± 50 kcal) than MF (1,866 ± 56 kcal) or FF (1,657 ± 50 kcal) women (P < 0.001). Adjusted nutrient intake did not differ between groups. All groups were at risk for inadequate intakes of vitamins A, E, C, and folate and did not meet recommended servings of all food groups. BF women consumed lunch and snacks more frequently, were less likely to diet, and reported higher intakes of grains and desserts than MF and FF women. CONCLUSIONS To help increase intakes of nutrients lacking in the diet and prevent postpartum weight gain, overweight women should be encouraged to increase fruits, vegetables, low-fat dairy, whole grains, legumes, and healthy types of fat, while decreasing refined grains, regular soda, sweetened beverages, and desserts.