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.

Effect of Child Gender and Psychosocial Factors on Physical Activity From Fifth to Sixth Grade.

BACKGROUND: Gender differences in physical activity (PA) trajectories during adolescence are well documented, yet little research has examined whether the determinants of these trajectories vary by child's gender. This study is one of few prospective examinations of gender differences in the influences of psychosocial and socioenvironmental factors on changes in objectively measured PA. METHODS: Students and parents from elementary and middle schools located in 2 school districts in South Carolina were enrolled in a prospective cohort study of changes in children's PA from elementary to middle school. Measures included children's and/or parents' ratings of various psychosocial and socioenvironmental factors as well as objectively measured PA, children's anthropometric characteristics, and neighborhood factors at fifth and sixth grades. RESULTS: Parents' reports of children's sport and class participation, parent-reported support for PA, and neighborhood resources for PA were protective against declines in PA for both boys and girls. The effects of 2 factors-children's self-efficacy and parents' leisure-time PA-on changes in PA over time were moderated by the child's gender. CONCLUSIONS: A better understanding of these dynamics may inform the development of interventions.

An Intervention to Increase Physical Activity in Children: A Randomized Controlled Trial With 4-Year-Olds in Preschools.

INTRODUCTION: A majority of preschool-aged children spend a significant portion of every weekday in a preschool or child care setting, where they typically participate in limited physical activity. This study determined if an ecologic physical activity intervention in preschools increases children's moderate- to vigorous-intensity physical activity (MVPA). DESIGN: RCT, with preschool as the unit of randomization and analysis. Child physical activity was measured by accelerometry. Mixed model analysis of covariance with preschool as a random variable was used to test the effects of the intervention on physical activity in the total group and in sex-specific subgroups. Data were collected in 2008-2010 and analyzed in 2012-2014. SETTING/PARTICIPANTS: Children in 4-year-olds' classrooms in 16 preschools, pair matched and assigned to intervention or control groups. INTERVENTION: The intervention focused on increasing children's physical activity by changing instructional practices. Researchers trained preschool teachers to engage children in physical activity during (1) structured, teacher-led physical activity opportunities in the classroom; (2) structured and unstructured physical activity opportunities at recess; and (3) physical activity integrated into pre-academic lessons. Research staff encouraged teachers to adapt the intervention to their classrooms. MAIN OUTCOME MEASURES: Minutes/hour of MVPA during the preschool day. RESULTS: In an analytic sample of 379 children (188 intervention, 191 control), those in the intervention schools engaged in significantly more MVPA than children in control schools (7.4 and 6.6 minutes/hour, respectively). This difference remained significant after adjusting for parent education and length of the school day (half versus full day). In the sex-specific analyses, the difference was significant for girls (6.8 vs 6.1 minutes/hour of MVPA, respectively) but not for boys (7.9 vs 7.2 minutes/hour, respectively). CONCLUSIONS: A flexible ecologic physical activity intervention that trains teachers to provide children with opportunities to be active throughout the school day increased MVPA in preschool children.

Prevalence of Compliance with a New Physical Activity Guideline for Preschool-Age Children.

BACKGROUND: Four expert panels from Australia, Canada, the United Kingdom, and the United States issued physical activity (PA) recommendations for young children that are quite similar. The aim of this study was to determine compliance with the new PA guideline (defined as ≥15 min/hr of total PA) in two independent samples of preschool children. METHODS: We conducted a cross-sectional study of children attending preschools in Columbia, South Carolina. A total of 286 children in one sample and 337 children in a second sample participated. The main outcome of interest was total PA (sum of light, moderate, and vigorous intensity activity) measured by accelerometry. Compliance with the PA guideline was determined for both samples. Separately for each sample, mixed logistic models were used to determine whether there were differences in compliance with the PA guideline between groups based on sex, race/ethnicity, parent education, and weight status, controlling for preschool. RESULTS: Total PA was 14.5 and 15.2 min/hr in the first and second samples, respectively. The prevalence of meeting the PA guideline was 41.6% and 50.2% in the first and second samples, respectively. In both samples, more males than females met the guideline (53.5% vs. 33.5% and 57.6% vs. 45.9%) in the first and second samples, respectively (p<0.05). CONCLUSIONS: Approximately one half of children in two independent samples met the guideline for PA in young children. Policies and practices designed to increase PA among preschool children are needed, given that most children are not meeting this PA guideline.

Enhancing interprofessional education: integrating public health and social work perspectives.

National stakeholders in health system improvement and patient safety including accreditation bodies have requested health professional educational programs to include multiple interprofessional experiences through didactic and experiential opportunities. Clinical and population health faculty at the University of South Carolina redesigned and expanded an introductory interprofessional course to include more than 500 students from public health, social work, medicine, pharmacy, and nursing. Students participated in 3 live class meetings and completed required online coursework to explore concepts related to social determinants of health and health disparities, health system improvement, patient safety, cultural competency, and ethics to address interprofessional education core competencies. Course modifications and expanded student enrollment improved understanding of key health concepts and appreciation of interprofessional collaboration.

Assessing preschool children's physical activity: how many days of accelerometry measurement.

The purpose of this study was to determine the minimum number of days of accelerometry required to estimate accurately MVPA and total PA in 3- to 5-year-old children. The study examined these metrics for all days, weekdays, and in-school activities. Study participants were 204 children attending 22 preschools who wore accelerometers for at least 6 hr per day for up to 12 days during most waking hours. The primary analysis considered the intraclass correlation coefficient (ICC) for each metric to estimate the number of days required to attain a specified reliability. The ICC estimates are 0.81 for MVPA-all days, 0.78 for total PA-all days, 0.83 for MVPA weekdays, 0.80 for total PA-weekdays, 0.81 for in-school MVPA, and 0.84 for in-school total PA. We recommend a full seven days of measurement whenever possible, but researchers can achieve acceptable reliability with fewer days, as indicated by the Spearman-Brown prophecy: 3-4 days for any weekday measure and 5-6 days for the all-days measures.

Study of Health and Activity in Preschool Environments (SHAPES): study protocol for a randomized trial evaluating a multi-component physical activity intervention in preschool children.

BACKGROUND: Physical inactivity is a recognized public health concern. Inadequate proportions of children in the U.S, including those of preschool age, are meeting physical activity recommendations. In response to low numbers of preschool children attaining appropriate physical activity levels, combined with the large number of young children who attend preschool, researchers have identified the need to devise interventions to increase physical activity at preschools. However, few multi-component interventions to increase physical activity in preschool children exist. The aims of this study were to observe the effects of a multi-component intervention on physical activity, sedentary behavior, and physical activity energy expenditure in 3-5 year-old children; identify factors that associate with change in those variables; and evaluate the process of implementing the multi-component intervention. The purpose of this manuscript is to describe the study design and intervention protocol. METHODS/DESIGN: The overall design of the Study of Health and Activity in Preschool Environments (SHAPES) was a two-year randomized trial (nested cohort design), with two conditions, two measurement occasions, and preschool serving as the unit of analysis. Sixteen schools (eight intervention and eight control) were enrolled. The intervention protocol was based on the social ecological model and included four main components: (a) indoor physical activity ("move inside"), (b) recess ("move outside"), (c) daily lessons ("move to learn"), and (d) social environment. Components were implemented using teacher and administrator trainings and workshops, site support visits, newsletters, and self-monitoring methods. Outcomes included accelerometer assessment of physical activity, sedentary behavior, and physical activity energy expenditure; weight status; and demographic factors; family/home social and physical environment; and parental characteristics. An extensive process evaluation battery was also used to monitor dose delivered by interventionists, completeness of intervention component delivery by teachers, and fidelity of teachers' implementation. DISCUSSION: The study will address important gaps relative to increasing physical activity in preschool children. Few studies to date have incorporated a multi-component approach, rigorous measurement protocol, and thorough evaluation of intervention implementation.

Identification of device-associated infections utilizing administrative data.

BACKGROUND: Health care-associated infections are a cause of significant morbidity and mortality in US hospitals. Recent changes have broadened the scope of health care-associated infections surveillance data to use in public reporting and of administrative data for determining Medicare reimbursement adjustments for hospital-acquired conditions. METHODS: Infection surveillance results for catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia were compared with infections identified by hospital administrative data. The sensitivity and specificity of administrative data were calculated, with surveillance data considered the gold standard. RESULTS: The sensitivity of administrative data diagnosis codes for CAUTI, CLABSI, and ventilator-associated pneumonia were 0%, 21%, and 25%, respectively. The incorporation of additional diagnosis codes in definitions increased the sensitivity of administrative data somewhat with little decrease in specificity. Positive predictive values for definitions corresponding to Centers for Medicare and Medicaid services-defined hospital-acquired conditions were 0% for CAUTI and 41% for CLABSI. CONCLUSIONS: Although infection surveillance methods and administrative data are widely used as tools to identify health care-associated infections, in our study administrative data failed to identify the same infections that were detected by surveillance. Hospitals, already incentivized by the use of performance measures to improve the quality of patient care, should also recognize the need for ongoing scrutiny of appropriate quality measures.

A cluster analysis of physical activity and sedentary behavior patterns in middle school girls.

PURPOSE: To identify similar patterns of physical activity (PA) and sedentary behavior in sixth-grade girls using cluster analysis; to determine which clusters of girls were associated with greater daily minutes of objectively measured PA; and to examine whether girls in these clusters experienced change in PA from sixth to eighth grade. METHODS: An adventitious cohort of girls (n = 957) from the Trial of Activity for Adolescent Girls were measured at sixth and eighth grade. Activities were identified using the 3-day physical activity recall and a self-report survey and used to create clusters of sixth-grade girls who had similar PA/sedentary behaviors. Accelerometry was used to assess PA in sixth and eighth grade. Data analysis consisted of FASTCLUS procedure and mixed model repeated measures analyses in SAS statistical software. RESULTS: Cluster analysis yielded six clusters (C1: educational sedentary; C2: sports and play; C3: organized sports teams/classes/lessons in past year; C4: active transport and chores; C5: electronic media; C6: sleep). Sixth-grade girls in C2 and C3 had greater average daily minutes of moderate-to-vigorous physical activity (MVPA), metabolic equivalent of a physical activity-weighted MVPA, and vigorous physical activity compared with other clusters (p < .05). In eighth grade, sedentary time increased and PA declined among girls in all clusters (p < .05). Girls in C2 had the greatest decline in PA, whereas girls' PA in C3 declined less. CONCLUSIONS: Encouraging participation in organized sports teams/class/lessons in middle school girls may promote greater MVPA and vigorous physical activity than other activities and may help to better sustain PA levels over time.

Results of the "Active by Choice Today" (ACT) randomized trial for increasing physical activity in low-income and minority adolescents.

OBJECTIVE: This study reports the results of the "Active by Choice Today" (ACT) trial for increasing moderate-to-vigorous physical activity (MVPA) in low-income and minority adolescents. DESIGN: The ACT program was a randomized controlled school-based trial testing the efficacy of a motivational plus behavioral skills intervention on increasing MVPA in underserved adolescents. Twenty-four middle schools were matched on school size, percentage minorities, percentage free or reduce lunch, and urban or rural setting before randomization. A total of 1,563 6th grade students (mean age, 11.3 years, 73% African American, 71% free or reduced lunch, 55% female) participated in either a 17-week (over one academic year) intervention or comparison after-school program. MAIN OUTCOME MEASURE: The primary outcome measure was MVPA based on 7-day accelerometry estimates at 2-weeks postintervention and an intermediate outcome was MVPA at midintervention. RESULTS: At midintervention students in the intervention condition engaged in 4.87 greater minutes of MVPA per day (95% CI: 1.18 to 8.57) than control students. Students in intervention schools engaged in 9.11 min (95% CI: 5.73 to 12.48) more of MVPA per day than those in control schools during the program time periods; indicating a 27 min per week increase in MVPA. No significant effect of the ACT intervention was found outside of school times or for MVPA at 2-weeks postintervention. CONCLUSIONS: Motivational and behavioral skills programs are effective at increasing MVPA in low-income and minority adolescents during program hours, but further research is needed to address home barriers to youth MVPA.

The faith, activity, and nutrition (FAN) program: design of a participatory research intervention to increase physical activity and improve dietary habits in African American churches.

BACKGROUND: African Americans are at increased risk for cardiovascular disease and cancer morbidity and mortality. Physical activity and healthy dietary practices can reduce this risk. The church is a promising setting to address health disparities, and community-based participatory research is a preferred approach. OBJECTIVES: Using a community-based participatory approach and the social ecologic model, the FAN trial aims to increase self-reported moderate-intensity physical activity and fruit and vegetable consumption and reduce blood pressure in African American church members. Secondary aims are to increase objectively measured moderate-intensity physical activity and fiber/whole grain consumption and reduce fat consumption. DESIGN: FAN is a group randomized trial (GRT) with two levels of clustering: participants (N=1279; n=316 accelerometer subgroup) within church and church within church cluster. In the first wave, seven clusters including 23 churches were randomized to an immediate intervention or delayed intervention. In subsequent waves, 51 churches were randomized to an immediate or delayed intervention. METHODS: Church committee members, pastors, and cooks participate in full-day trainings to learn how to implement physical activity and dietary changes in the church. Monthly mailings and technical assistance calls are delivered over the 15-month intervention. Members complete measurements at baseline and 15 months. A detailed process evaluation is included. SUMMARY: FAN focuses on modifying the social, cultural, and policy environment in a faith-based setting. The use of a community-based participatory research approach, engagement of church leaders, inclusion of a detailed process evaluation, and a formal plan for sustainability and dissemination make FAN unique.

Heart Healthy and Ethnically Relevant (HHER) Lifestyle trial for improving diet and physical activity in underserved African American women.

BACKGROUND: African American women are at increased risk for CVD morbidity and mortality relative to white women. Physical inactivity and poor dietary habits are modifiable health behaviors shown to reduce CVD risk. Community health centers have the potential to reach large numbers of African Americans to modify their risk for CVD, yet few lifestyle counseling interventions have been conducted in this setting. METHODS: The HHER Lifestyle trial is a randomized controlled trial to compare the effects of a standard care intervention (provider counseling, nurse goal setting, and educational materials) to a comprehensive intervention (standard care intervention plus 12 months of telephone counseling and tailored print materials) on changes in physical activity and dietary fat consumption in financially disadvantaged African American women at 6 and 12 months. Secondary outcomes are body mass index, central adiposity, and total cholesterol. Potential mediators of outcome are self-efficacy for overcoming barriers, social support, and decisional balance. RESULTS: African American women (N=266; 130 standard care, 136 comprehensive intervention) 35 years and older from nine clinics within two community health centers were enrolled. Most participants were overweight or obese with existing chronic health conditions. CONCLUSION: The HHER Lifestyle trial is unique in that it targets financially disadvantaged African American women from community health centers, incorporates a standard care intervention into a routine clinical appointment, and includes a comprehensive process evaluation. The design will permit further research examining the added effect of regular telephone counseling and tailored print materials to a primary care provider and nurse intervention.

Logistic regression with incomplete covariate data in complex survey sampling: application of reweighted estimating equations.

Weighted survey data with missing data for some covariates presents a substantial challenge for analysis. We addressed this problem by using a reweighting technique in a logistic regression model to estimate parameters. Each survey weight was adjusted by the inverse of the probability that the possibly missing covariate was observed. The reweighted estimating equations procedure was compared with a complete case analysis (after discarding any subjects with missing data) in a simulation study to assess bias reduction. The method was also applied to data obtained from a national health survey (National Health and Nutritional Examination Survey or NHANES). Adjusting the sampling weights by the inverse probability of being completely observed appears to be effective in accounting for missing data and reducing the bias of the complete case estimate of the regression coefficients.

Social and environmental factors associated with preschoolers' nonsedentary physical activity.

The twofold purposes of the investigation were (a) to describe with direct observation data the physical activity behaviors and the accompanying social and environmental events of those behaviors for children in preschools and (b) to determine which contextual conditions were predictors of moderate to vigorous physical activity (MVPA) and nonsedentary physical activity (i.e., light activity + MVPA) for 3-, 4-, and 5-year-old children during their outdoor play. The results indicate that preschoolers' physical activity is characterized as sedentary in nature throughout their preschool day (i.e., 89% sedentary, 8% light activity, and 3% MVPA). During outdoor play periods, when children are most likely to be physically active, some contextual and social circumstances better predict their physical activity. Implications for policy makers, practitioners, and researchers are discussed.

Policies and characteristics of the preschool environment and physical activity of young children.

OBJECTIVE: The purpose of this study was to examine policies and characteristics of preschools and the extent to which they influence the physical activity of 3- to 5-year-old children during the preschool day. METHODS: A total of 299 children from 20 preschools wore accelerometers for an average of 8.1 hours/day (SD: 1.5 hours/day), for 5.5 days (SD: 2.1 days). A researcher completed the Early Childhood Environment Rating Scale-Revised for each preschool to assess quality. Classrooms and playgrounds were measured, and the preschool director was interviewed about physical activity policies. For each policy or characteristic, preschools were divided into 2 groups on the basis of whether the characteristic/policy was presumed to promote or not promote physical activity. RESULTS: Children spent fewer minutes per hour in sedentary activity and more minutes per hour in moderate/vigorous physical activity in preschools that had higher quality scores, less fixed playground equipment, more portable playground equipment, lower use of electronic media, and larger playgrounds. Five preschools had all 5 of these characteristics, and children in those preschools had significantly more moderate/vigorous physical activity minutes per hour and fewer sedentary minutes per hour compared with children in the other preschools. CONCLUSION: Children in the top 5 physical activity-promoting preschools accumulated >60 minutes of moderate/vigorous physical activity per day, compared with the children in the other preschools, who accumulated <60 minutes of moderate/vigorous physical activity per day.

Correlates of physical activity among African American and white women.

OBJECTIVE: To compare potential correlates of physical activity between African American and white women. METHODS: A random-digit-dialed telephone survey was conducted in central South Carolina. Bivariate and multivariate analyses focused on women aged 18+ (N = 1176). RESULTS: African American women reported greater maintenance of sidewalks and public parks than did white women, who reported higher physical activity, exercise self-efficacy, access to indoor walking facilities, and knowledge of mapped-out walking routes. Exercise self-efficacy was the only significant correlate of physical activity among both African American and white women. CONCLUSIONS: Self-efficacy was a robust cross-sectional correlate of physical activity in women.

The effect of question order on reporting physical activity and walking behavior.

BACKGROUND: Question order might affect self-reported regular physical activity (PA) measured with items from the Behavioral Risk Factor Surveillance System (BRFSS) PA module. METHODS: A telephone survey was conducted using 2 forms (N = 1004, N = 212) with varying PA question order. The standard form presented moderate-PA, vigorous-PA, and walking questions, in that order, whereas the alternate form presented walking questions, followed by moderate-PA, and then vigorous-PA questions. Weighted, adjusted rates of vigorous PA, walking, meeting the Centers for Disease Control and Prevention (CDC) recommendation for moderate or vigorous PA, and moderate PA from each form were compared. RESULTS: Vigorous PA and walking were similar regardless of question order. Meeting the CDC recommendation for moderate or vigorous PA was reported less often with the alternate form among 18- to 34-year-olds. Less moderate PA was reported with the alternate form overall and among 18- to 34-year-olds, women, whites, and those with a high school education or less. CONCLUSION: Estimating PA and walking across sociodemographic strata with differing patterns of PA requires asking moderate-PA and vigorous-PA questions before walking questions. Asking walking questions first might lead to bias, especially for moderate PA. Walking, added to a survey with BRFSS moderate and vigorous PA items, should be placed after moderate and vigorous PA. Walking questions first may cause bias, especially for moderate PA.

An overview of "The Active by Choice Today" (ACT) trial for increasing physical activity.

BACKGROUND: Although school-based behavioral interventions for increasing physical activity (PA) in children and adolescents have been conducted, little evidence suggests that these curriculum-based approaches lead to increases in overall activity outside of program days. The overall goal of the "Active by Choice Today" (ACT) trial is to expand the body of knowledge concerning the factors that influence long-term increases in PA in underserved adolescents (low socioeconomic status, minorities) during their middle school years. DESIGN AND SETTING: An overview of the ACT study design, theoretical framework, process evaluation, and primary hypotheses is presented. The trial involves twenty-four middle schools (1560 6th graders) in South Carolina that are randomly assigned to one of two after-school programs (motivational and life skills intervention, or general health education). INTERVENTION: The intervention integrates constructs from Self-Determination and Social Cognitive Theories to enhance intrinsic motivation and behavioral skills for PA. The intervention targets skill development for PA outside of program days and the after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) is designed to positively impact cognitive mediators (self-efficacy, perceived competence), and motivational orientation (intrinsic motivation, commitment, positive self-concept). MAIN HYPOTHESES/OUTCOMES: It is hypothesized that the 17-week motivational and life skills intervention will lead to greater increases in moderate-to-vigorous PA (based on 7-day accelerometry estimates) at post-intervention as compared to the general health education program. CONCLUSIONS: Implications of this innovative school-based trial are discussed.

Perceived individual, social, and environmental factors for physical activity and walking.

BACKGROUND: Few studies have explored associations of individual, social, and environmental factors with physical activity and walking behavior. METHODS: A random-digit-dial questionnaire, which included selected individual, social, and environmental variables, was administered to 2025 adults, age 18 y and older, in two adjacent counties in a southeastern state. Logistic regressions were conducted adjusting for age, race, sex, education, and employment. RESULTS: In multivariate models, somewhat different variables were associated with physical activity versus regular walking. Self-efficacy (OR = 19.19), having an exercise partner (OR = 1.47), recreation facilities (OR = 1.54), and safety of trails from crime (OR = 0.72) were associated with physical activity level; while self-efficacy (OR = 4.22), known walking routes (OR = 1.54), recreation facilities (OR = 1.57-1.59), and safety of trails from crime (OR = 0.69) were associated with regular walking behavior. CONCLUSIONS: Physical activity and walking behaviors were associated with similar variables in this study.