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After Baby Fitness Challenge: Moms’ Way to Better Health The Importance of Pre- and Inter-Conceptional Health July 18, 2012 Funding for this program was.

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Presentation on theme: "After Baby Fitness Challenge: Moms’ Way to Better Health The Importance of Pre- and Inter-Conceptional Health July 18, 2012 Funding for this program was."— Presentation transcript:

1 After Baby Fitness Challenge: Moms’ Way to Better Health The Importance of Pre- and Inter-Conceptional Health July 18, 2012 Funding for this program was made possible in part by the HHS, HRSA, H59MC12788. The views expressed in written materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of the Department of Health and Human Services; nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

2 After Baby Fitness Challenge: Moms’ Way to Better Health Sandra C. Mobley, PhD, RN, Project Director/Co-Investigator (presenting) Crystal E. Neal, MS, Research Associate Deborah Young-Hyman, PhD, Evaluator/Co-Investigator Marlo Vernon, MS, Research Associate Jodi Hudgins, MSN, RN, ECHS Clinical Services Coordinator LaSonya Griffin, BSN, RN, ECHS Case Manager JoeAnn McGhee, RN, ECHS Case Manager Laura Tucker, BSN, RN, ECHS Case Manager Betty Burnett, BA, ECHS Advocate Judy Whitfield, ECHS Advocate Jeannie Hatfield, RD Don Sutherland, PhD, ECHS Database Administrator Debra Griffin, BA, Outreach Coordinator Mark Wilkinson, CPA, ECHS Accountant

3 Presentation Objectives Review statistics related to obesity in the United States Connect goals and objectives of this research project to measures collected over the course of subject’s enrollment period. Describe the intervention components of the weight reduction program for postpartum women. Examine the results of the study to date. List the life style challenges and perceptions of rural women regarding their health and well-being. Identify ideas for furthering intervention work with regard to improving the weight, mental health and well-being of women of reproductive age.

4 Definitions BMI = body mass index / ht:wt BMI between 25 and 29.9 = overweight BMI of 30 or higher = obese BMI of 16 or less = anorexic waist circumference --abdominal fat is a predictor of risk for obesity-related diseases

5 Percent of Obese (BMI > 30) in U.S. Adults


7 2009 Age-Adjusted Estimates of the Percentage of Adults Who Are Obese in Georgia

8 Enterprise Community Healthy Start

9 Research Design Design Comparative effectiveness research McDuffie –intervention/ Burke –control Enrollment criteria ECHS clients At least 18 years of age Postpartum 6 weeks-6 months BMI > 25

10 Goals and Objectives of Research Goal: Reduce the Body Mass Index (BMI) By 7/31/12: Objective 1: 90% of participants will increase overall level of physical activity (PA), regardless of type of PA, as measured by PA diary, to 1 hour twice per week. Objective 2: 90% of participants will attend monthly group nutrition sessions at a minimum of 75% of sessions annually. Objective 3: 90% of participants will increase intake of fruits and vegetables from baseline, based on two 24-hour dietary recalls. Objective 4: 90% of participants will increase nutrition knowledge from baseline, based on a test of general nutrition knowledge.

11 Goals and Objectives of Research Goal: Improve depression scores on either instrument at each repeated measure By 7/31/12: Objective 1: 60% of participants will reduce levels of depression, based on changes in Edinburgh Postnatal Depression Scale (EPDS) and/or Beck Depression Inventory (BDI) scores at 6 and 12 months postpartum. Objective 2: 60% of participants will improve quality of well-being, based on SF-12v2 Health and Well-Being Survey (SF-12) scores at 6 and 12 months postpartum. Objective 3: 60% of participants who have positive depression screens will complete referrals for mental health counseling.

12 Research Protocol ECHS clients sign Informed Consent Form Baseline measures are completed Participants receive a free gym membership 2 nutrition classes per month 120 minutes of exercise per week Weekly weight and waist measurements 3, 6, 9, and 12 month assessments at ECHS office or client’s home Participants may be in program 1 year

13 Interventions Case Management (intervention and control groups) Intervention Group Only – Nutrition Education (intervention group only) Classes led/developed by RD or Research Associate Open to children and family members Held 4 times per month – Exercise Y membership (child care, card scanning capability) Classes led by Research Associate – Incentives Y membership, free pedometer, WalMart gift card

14 Nutrition Class Topics Food Guide Pyramid (which became choose my plate 2011) Fat- substituting fat in cooking Calories and maintaining food records Meal patterns and sample menus Sodium Food Safety Nutrition for Breastfeeding Moms Dairy Foods and Importance of Calcium Fiber and Whole Grains Nutrition Facts Label Lean protein foods Eating healthy when dining out Fruits and Veggies- why is variety important? Obesity, hypertension and diabetes relationship Being a role model for your children Eating better on a budget / Wise shopping

15 Flow Chart

16 Subject Characteristics (@3months) All Subjects (n = 100) Intervention (n = 58) Control (n = 42) Mean ± SDRangeMean ± SDRangeMean ± SDRange Age26.0 ± 5.918 - 4324.8 ± 4.718 – 4027.7± 6.8 1 19 - 43 # of Risks 3.2 ± 2.0 0 - 12 3.1 ± 1.9 0 – 9 3.4 ± 2.1 0 – 12 Education11.9 ± 1.7 7 – 1611.7 ± 1.6 7 – 1512.1 ± 1.9 8 – 16 Gravida 2.7 ± 1.9 1 – 9 2.6 ± 1.8 1 – 9 2.9 ± 2.0 1 – 7 1 : Between groups, t = 2.4, p <.02

17 Subject Characteristics All Subjects (n = 100) Intervention (n=58) Control (n = 42) Race African American 91%90%93% Method of Feeding at Baseline 1 Breast13% 2%27% Bottle72%82%61% Both15%17%12% Marital Status Single 82%83%81% Married 16%15%17% Divorced 2% Father Involvement None 21%28%12% Visits Occasionally 17%15%19% Visits Weekly 9% 7%12% Visits Daily 19%21%17% Lives in Home 34%29%41% 1 : Between groups, X 2 = 13.2, p<.01

18 Healthy Weight Outcomes

19 Physical Activity Levels

20 Physical Activity Recall

21 Physical Activity

22 Light Activities Reported

23 Physical Activity Moderate Activities Reported

24 Physical Activity Exercise Activities Reported


26 Quick List Outline of the meal – Enter meal time, name and location – List foods and beverages – Enter exactly as reported Prompt questions – “After midnight, what was the first time you had something to eat or drink?” – “What did you have at that time?” – “Did you have anything else at that time?” Repeat until subject answers “no.” Review for omissions



29 Details Provides level of food detail required for research – Chicken drumstick – Skin eaten – Fried, breaded- coating eaten – Home prepared – Pan fried – In Mazola corn oil – With regular salt

30 Nutrition Data System for Research Most accurate and comprehensive nutrient calculation software available for research Commonly referred to as NDS-R Uses the multi-pass approach for conducting dietary recalls

31 NDS-R Program Uses the multi-pass approach – The participant “recalls” Make a brief list Review for omissions Obtain details Review the details – The interviewer becomes actively involved in the participant’s “recollection” – Reduces the incidence of under-reporting

32 Comparisons of Nutrient Intake Baseline6 months12 months Recommended Intake 1 Mean ± SD Range Mean % of Energy Mean ± SD Range Mean % of Energy Mean ± SD Range Mean % of Energy MinMaxMinMaxMinMax Energy (kCal) 1658.5 ± 646.1 184.33224.6 1366.6 ± 864.8* 450.92468.1 1281.5 ± 424.8 @ 6212142.5 Fat (g) 20-35% 65.9 ± 33.2 7.5164.635.5 54.9± 21.9 + 20.2116.236.355.5 – 21.8 ++ 26.998.036.7 Carbohydrate (g) 130g (45-65%) 207.5 ± 91.5 21.0476.049.8 167.7 ± 88.3 41.5403.047.4 141.5 ± 42.8 77.5211.848.0 Protein (g) 46g (10-35%) 60.8 ± 26.7 7.74127.015.3 54.8 ± 18.0 24.888.516.6 55.8 ± 27.2 9.6115.516.2 Trans Fatty Acids (g) 5.2g ± 3.6.0018.7 3.6 ± 2.8 ×.08.6 2.4 ± 2.4 xx 0.0 –6.6 Monounsaturated Fatty Acids (g) 10% 25.5 ± 13.3 3.0168.713.7 21.8 ± 8.5 8.342.814.4 22.2 ± 9.0 12.241.514.7 Polyunsaturated Fatty Acids (g) 10% 12.g ± 7.2 10.2 ± 6.9 3.530.96.9 10.3 ± 4.0 Dietary Fiber (g) 20-30g 10.7 ± 10.1 1.974.8 6.7 ± 3.6 b 1.515.7 7.5 ± 3.2 bb 2.613.22 Sodium (mg)<2300mg2943.5 ± 1330.4538.87199.5 2526.5 ± 714.0 c 1028.54066.6 2534.2 ± 1089.8 d 732.74521.2 Baseline ∆ 6mBaseline ∆ 12m * t = -2.25, p<.03 ** t = -3.54, p<.003 + t = -2.12, p<.05 ++ t = -3.82, p<.01 x t = -2.17, p<.04 xx t = -3.65, p<.01 b t = -2.85, p<.01 bb t = -2.08, p<.05 c t = -2.39, p<.03 d t = -2.30, p<.04 1 Dietary Guidelines for Americans, 2010, USDA

33 Nutrition Knowledge Items Whole milk is a good source of: a. vitamin Kb. vitamin A c. vitamin E d. fibere. vitamin D Canned soups, ham and pickles are very high in: a. thiamin (B1) b. fiber c. zincd. vitamin Ee. sodium Which food contains the greatest amount of fiber per cup? a. brownies b. corn flakes c. iceberg lettuced. kidney beans e. pasta Not enough _________ in the diet has been linked to birth defects involving the brain and spine (spina bifida). a. calciumb. folic acid c. iron d. vitamin A e. vitamin C Which food below does NOT contain carbohydrates? a. appleb. cokec. hamburger meat d. milk e. peas

34 Nutrition Knowledge

35 Intake of Fruits and Vegetables

36 Healthy Weight Process Measure Nutrition Class Attendance At 3 months in the program, 6/40 or 15.0% had attended 75% of classes. At 6 months in the program, 4/33 or 12.1% had attended 75% of classes. At 9 months in the program, 3/22 or 13.6% had attended 75% of classes. At 12 months in the program, 3/15 or 20.0 % had attended 75% of classes.

37 Healthy Weight — Reduce BMI

38 Mental Wellness Outcomes



41 Mental Wellness Outcomes Depression Scores Significant Differences between groups BDI 12mN Mean ± SD tp Intervention154.75 ± 1.2 2.1.05 Control179.0 ± 2.2 EPDS 12mN Mean ± SD tp Intervention153.1 ± 3.1 2.2.03 Control176.6 ± 5.7 Beck Depression Inventory, Clinical cutoff, ≥13 Edinburgh Postnatal Depression Survey, Clinical cutoff, ≥ 10

42 Mental Wellness Outcomes Quality of Well-Being

43 Mental Wellness Process Measure Completed Mental Health Referrals Of the 72 enrolled subjects, 68 had depression screens. Of these 68, 21 (30.9%) had positive depression screens. Of these 21, 7 (33.3%) were referred for mental health counseling. Of these 7 who were referred, none completed a mental health referral.

44 Summary The program reached target population Limitation-many did not complete the study Population very challenged ( quality of well-being survey ) – Depressed but don’t think they are (inaccurate perceptions of self) – Sedentary but that’s their lifestyle – Diminished quality of life but see their life as normal

45 Summary Women in the intervention group did not have an increase in BMI over the 12-month intervention course, in comparison to the control group where a significant increase in BMI occurred from baseline to the 12-month evaluation (p<0.004) Regarding depression screening, the intervention group had a significant improvement from baseline to 12 months, whereas the control group did not, resulting in a significant difference in depression scores as measured by the EPDS (p<0.03) and the BDI (p<0.05) between groups at 12 months.

46 Summary In the intervention group only, the physical well-being score improved significantly from baseline to 6 months (p<0.03) and the mental wellness scale improved significantly from 6 to 12 months (p<0.05). Caloric intake in the intervention group decreased significantly at both 6 and 12 months from baseline. Intervention women decreased caloric intake on average 277 calories per day (p<0.003). This decrease stabilized their weight; their exercise did not. Exercise (walking, aerobics, dancing) increased in the intervention group between baseline and 6 months (p<0.05) and decreased back to baseline between 6 and 12 months.

47 Summary Household activities increased significantly in the intervention group from baseline to 12 months (p<0.05). Amount of time spent in work-based physical activity did not change significantly in the intervention group at any time period. However, time spent in child-care activities decreased significantly in the intervention group between baseline and 12 months (p<0.02). Despite a decrease in caloric intake, mothers’ decreased physical activity in the intervention group resulted in no overall change in BMI. In contrast, BMI in the control group significantly increased (p<0.004).

48 Implications for future research Service project provides a platform for natural experiment/study – We feel we are getting real data from the subjects, b/c we have relationships with them Evaluation should be built into service projects b/c more cost effective, community based, and generalizable Consider for intervention modifications: – Include children and family members in NE and PA – Include best friend as buddy/partner/coach Interventions may lead to primary prevention of obesity among children of high risk women

49 Implications for practice Program design – Include children and family members in NE and PA – Include best friend as buddy/partner/coach – If community environment permits, include walking activities in conjunction with food shopping or stroller groups – Use texting and Facebook for communication Challenges – Participant transportation – Participants’ work schedules – Lack of self-motivation from participants – Lack of daily structure

50 Lessons learned – Designated staff for coaching specifically focused on nutrition and exercise is necessary – Sustaining motivation seems to be a significant barrier to intervention success. – An obesigenic lifestyle appears to be entrenched in this population and multi-generational.

51 Conclusions We reached the intended women. We successfully implemented a program with few community resources and small budget. Approach and method – a) proved to be efficacious and – b) impacts the rising tide of obesity and obesity related diseases among the highest risk women.

52 Thank you!

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