Infant Feeding Support for Pregnant and Postpartum Parents With Intellectual and Developmental Disabilities: Perspectives of WIC Staff.

OBJECTIVE: To describe the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) staff experiences, perceptions, and training needs surrounding the provision of infant feeding support for parents with intellectual and developmental disabilities (IDD). METHODS: We conducted in-depth semistructured interviews between October and November 2021 with Maryland WIC staff (N = 10) who provide infant feeding counseling and support. We analyzed interviews using conventional content analysis. RESULTS: Three themes were identified: identifying and documenting IDD, facilitating effective communication and infant feeding education, and assessing WIC staff competence and readiness. CONCLUSIONS AND IMPLICATIONS: The interviews suggested the need to explore the risks and benefits of routine and compassionate processes for identifying and documenting disability, create accessible teaching materials that facilitate understanding and engagement, and educate and train staff to provide tailored support in WIC. Engaging parents with IDD to better understand their perspectives and experiences should guide future efforts to improve inclusivity and accessibility.

Impact of consuming a Mediterranean-style diet during pregnancy on neurodevelopmental disabilities in offspring: results from the Boston Birth Cohort.

Background: While consuming a Mediterranean-style diet (MSD) among pregnant women is expected to affect offspring neurodevelopment, the current evidence is limited. This prospective birth cohort study aimed to explore the association of maternal MSD with neurodevelopmental disabilities (NDD) in offspring, especially among children born to mothers with overweight or obesity (OWO) and/or diabetes mellitus (DM) since they have a higher risk for oxidative stress and immune/metabolic disturbances. Methods: We analyzed data from a subgroup of mother-child dyads enrolled in the Boston Birth Cohort. Maternal dietary information (via food frequency questionnaires, Food frequency questionnaires [FFQ]) and sociodemographic information were obtained via in-person interviews within 24 to 72 hours postpartum. Maternal clinical information and child diagnosis of NDD including autism, attention-deficit/hyperactivity disorder (ADHD), and other developmental disabilities (DD) were extracted from medical records. A Mediterranean-style diet score (MSDS) was calculated using the FFQ. The association of maternal MSDS with NDD, autism, ADHD, and other DD was evaluated using multivariable logistic regression models adjusted for pertinent covariates. Results: This study included 3153 mother-child pairs, from which we identified diagnoses of 1362 (43.2%) NDD, including 123 (3.9%) case of autism, 445 (14.1%) ADHD, and 794 (25.2%) other DD. In the overall sample, women with a higher maternal MSDS (per standard deviation increase) were less likely to have offspring with NDD (adjusted odds ratio [OR]: 0.904, 95% confidence interval [CI]: 0.817-1.000; P value: 0.049). Using MSDS quintile 1 as the reference, being in the combined group of quintiles 3-5 was associated with a 26% lower likelihood of NDD (adjusted OR: 0.738, 95% CI: 0.572-0.951; P value: 0.019). When stratified by mothers with OWO/DM vs. without OWO/DM, the association between maternal MSDS and offspring NDD was greater in children born to mothers with OWO/DM. Conclusions: In this prospective birth cohort, a higher maternal MSDS was associated with a lower likelihood of NDD in the offspring. Furthermore, this association of maternal MSDS with offspring NDD was greater in children born to women with OWO/DM. More studies are needed to replicate the findings and further analyze NDD subgroups and explore underlying molecular pathways.

The Impact of the COVID-19 Pandemic on the Experiences and Operations of Sponsors of the Summer Food Service Program in Maryland, USA: A Multiphase Mixed Methods Study.

During the COVID-19 pandemic, the Summer Food Service Program (SFSP) was allowed to operate in untraditional non-summer months to ensure children did not lose access to free and reduced-priced nutritious meals when schools were mandated to close in the United States. This study assessed the impact of the pandemic on the operations and experiences of Summer Food Service Program (SFSP) sponsors in the state of Maryland during the COVID-19 pandemic in 2020 (Phase I) and 2021 (Phase II). This study used a multiphase explanatory sequential mixed methods design with qualitative prioritization. Maryland SFSP sponsors completed an online survey (Phase I: n = 27, Phase II: n = 30), and semi-structured in-depth interviews were conducted with a subset of sponsors who completed the survey (Phase I: n = 12, Phase II: n = 7). Inductive and deductive analyses were used for qualitative data, and descriptive statistics were used for quantitative data. The COVID-19 pandemic caused SFSP sponsors to change their operations. Sponsors were primarily concerned about staff safety/burnout and decreased participation. Sponsors perceived waivers implemented by the United States Department of Agriculture to be crucial in enabling them to serve meals to children during the pandemic. The findings from our study support advocacy efforts to permanently implement waivers and provide free school meals for all children.

Engagement With and Acceptability of Digital Media Platforms for Use in Improving Health Behaviors Among Vulnerable Families: Systematic Review.

BACKGROUND: The use of digital communication platforms to improve health behaviors has increased dramatically over the last decade. Public health practitioners have adopted digital communication technologies such as text messages, mobile apps, and social media to reach diverse populations. However, the effectiveness of digital communication platforms used by community-serving agencies remains unclear, and patterns of engagement and acceptability of different platforms have not been studied. OBJECTIVE: This review aimed to identify the types of digital communication strategies used by community-serving organizations to promote healthy behaviors, assess the strength of evidence for health behavioral change, and describe the degree of consumer engagement with and acceptability of these strategies. The study population included low-income pregnant women, parents of young children, and adolescents. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Scopus, Web of Science, CINAHL, and APA PsycInfo, covering research conducted from 2009 to 2022. Studies were included if they examined the use of digital communication (ie, texting, mobile apps, or social media) to promote healthy behaviors in the target population. Risk of bias and strength of evidence were assessed using the Effective Public Health Practice Project Risk of Bias tool and criteria from Agency for Healthcare Research and Quality, respectively. RESULTS: Twenty-three peer-reviewed research studies published between 2012 and 2022, conducted in the United States, the United Kingdom, and Australia, were included in the review. The sample comprised studies exploring the use of texting (n=12), apps (n=6), social media (n=3), and multiple platforms (n=2; eg, texting and mobile apps). Targeted health behaviors included healthy diet, physical activity, obesity prevention, healthy pregnancy, breastfeeding, vaccine use, smoking cessation, and nutrition benefit redemption. The sample included 8 randomized controlled trials, 6 pretest-posttest design, 3 mixed methods studies, 2 pilot studies, 1 feasibility study, 1 prospective cohort study, 1 descriptive study, and 1 cross-sectional study. The median sample size was 77.5. There was no strong evidence to suggest the effectiveness of digital media campaigns in improving health behaviors; however, there were moderate to high levels of engagement and high levels of acceptability across digital platforms. CONCLUSIONS: Low-income pregnant women, parents of young children, and adolescents demonstrated moderate levels of engagement with and high levels of acceptability of digital media health campaigns conducted by community-serving agencies. The effectiveness of these strategies in improving health behaviors was inconclusive. Additional rigorous studies with larger sample sizes are required. In addition, more research is required to consistently measure and report participants' engagement with each platform. Digital communication platforms are critical tools for public health practitioners, and future investigations of the effectiveness of these platforms in engaging clients and improving health behaviors will maximize client services.

Breastfeeding Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children: A Systematic Review.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) promotes and supports breastfeeding for low-income women and children. A prior review reported negative associations of WIC with breastfeeding outcomes. WIC food package changes in 2009 increased breastfeeding support. OBJECTIVE: The objectives of this systematic review were to 1) evaluate evidence on WIC participation and breastfeeding outcomes and 2) evaluate breastfeeding outcomes of WIC participants before versus after the 2009 food package. DATA SOURCES: PubMed, Embase®, CINAHL, ERIC, SCOPUS, PsycINFO, and the Cochrane Central Register of Controlled Trials for papers published January 2009 to April 2022. ELIGIBILITY CRITERIA: Included studies compared breastfeeding outcomes (initiation, duration, exclusivity, early introduction of solid foods) of WIC participants with WIC-eligible nonparticipants, or among WIC participants before versus after the 2009 package change. STUDY APPRAISAL METHODS: Two independent reviewers evaluated each study and assessed risk of bias using EHPHP assessment. RESULTS: From 13 observational studies we found: 1) moderate strength of evidence (SOE) of no difference in initiation associated with WIC participation; 2) insufficient evidence regarding WIC participation and breastfeeding duration or exclusivity; 3) low SOE that the 2009 food package change is associated with greater breastfeeding exclusivity; 4) low SOE that WIC breastfeeding support services are positively associated with initiation and duration. LIMITATIONS: Only observational studies, with substantial risk of bias and heterogeneity in outcomes and exposures. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: WIC participation is not associated with a difference in breastfeeding initiation compared to WIC-eligible nonparticipants, but the 2009 food package change may have improved breastfeeding exclusivity among WIC participants and receipt of breastfeeding support services may have improved breastfeeding initiation and duration.

Strategies to Improve Adolescent Food Security from the Perspectives of Policy Advocates, Parents, and Adolescents.

This study explored strategies to improve adolescent food security using semi-structured in-depth interviews with 9 policy advocates, 12 parents and 15 adolescents aged between 17 and 20 years, living in households who were eligible for the Supplemental Nutrition Assistance Program in 2020. This study was part of a larger evaluation of adolescent food insecurity conducted in Baltimore, Maryland, USA during the COVID-19 pandemic. Three key strategies arose during analysis-improving federal nutrition assistance programs for households, federal nutrition assistance programs for individual adolescents, and leveraging school programs and resources. Respondents described concordant views regarding the role of the Supplemental Nutrition Assistance Program in supporting households but held discordant views about the role of other federal programs, such as the school nutrition programs and Pandemic Electronic Benefit Transfer program. The results of this study provide important insights about policy and programmatic supports that may assist adolescents to acquire food for themselves and their families. Future research should test how federal programs and policies specifically impact food security and nutrition for adolescents.

Diet Quality and Contextual Factors Influencing Food Choice among Adolescents with Food Security and Food Insecurity in Baltimore City.

This study evaluated differences in overall diet quality, diet quality components, and food-related contextual factors between adolescents with food security and those with food insecurity. Mixed methods analysis was conducted on data from three 24-h dietary recalls from 61 adolescents ages 14-19 years old living in Baltimore, Maryland, USA in 2020-2021. All adolescents were sampled from households eligible for the Supplemental Nutrition Assistance Program in 2020. There were no significant differences in overall diet quality or components between adolescents with food security and those with food insecurity in this sample, except for seafood and plant proteins, which was higher for adolescents with food insecurity. Qualitative analysis found that adolescents were largely influenced by their parents and the home food environment, and that workplace environments enabled adolescents to eat foods high in refined grains, sugar, and saturated fat. These findings provide insight about the experiences of low-income adolescents during times when they are home for prolonged periods (i.e., emergency school closures, summer, and winter breaks). Programs and policies that aim to improve healthy food access may positively impact adolescent food security and diet quality, and it is important to ensure that healthy foods are available and accessible to adolescents in the places where they spend the most time. Multilevel interventions in the home, school, and workplace may be most effective in encouraging healthy eating behaviors among adolescents.

Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children : A Systematic Review.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve maternal and child health outcomes. In 2009, the WIC food package changed to better align with national nutrition recommendations. PURPOSE: To determine whether WIC participation was associated with improved maternal, neonatal-birth, and infant-child health outcomes or differences in outcomes by subgroups and WIC enrollment duration. DATA SOURCES: Search (January 2009 to April 2022) included PubMed, Embase, CINAHL, ERIC, Scopus, PsycInfo, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Included studies had a comparator of WIC-eligible nonparticipants or comparison before and after the 2009 food package change. DATA EXTRACTION: Paired team members independently screened articles for inclusion and evaluated risk of bias. DATA SYNTHESIS: We identified 20 observational studies. We found: moderate strength of evidence (SOE) that maternal WIC participation during pregnancy is likely associated with lower risk for preterm birth, low birthweight infants, and infant mortality; low SOE that maternal WIC participation may be associated with a lower likelihood of inadequate gestational weight gain, as well as increased well-child visits and childhood immunizations; and low SOE that child WIC participation may be associated with increased childhood immunizations. We found low SOE for differences in some outcomes by race and ethnicity but insufficient evidence for differences by WIC enrollment duration. We found insufficient evidence related to maternal morbidity and mortality outcomes. LIMITATION: Data are from observational studies with high potential for selection bias related to the choice to participate in WIC, and participation status was self-reported in most studies. CONCLUSION: Participation in WIC was likely associated with improved birth outcomes and lower infant mortality, and also may be associated with increased child preventive service receipt. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020222452).

Baby Friendly Hospital Designation and Breastfeeding Outcomes Among Maryland WIC Participants.

OBJECTIVES: The Baby-Friendly Hospital Initiative is an effective intervention to support maternal practices around breastfeeding. However, little is known about its impact on participants of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The purpose of this study was to evaluate whether Baby Friendly Hospital (BFH) designation in Maryland improved breastfeeding practices among Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants. METHODS: Breastfeeding practices of WIC participants (22,543 mother-infant dyads) were analyzed utilizing WIC management information system de-identified data from four Maryland WIC agencies during 2010-12 and 2017-19. Participants lived in areas served by a hospital that became BFH in 2016 or remained non-BFH. Pre-post implementation breastfeeding practices (breastfeeding initiation, at 3 months and 6 months) of women associated with a BFH were compared to women associated with a non-BFH using propensity score weighting and a difference-in-difference modeling. RESULTS: From pre to post intervention no differences in breastfeeding initiation or any breastfeeding at 6 months were attributable to BFH status. There was some evidence that BFH designation in 2016 was associated with an absolute percent change of 2.4% (P = 0.09) for any breastfeeding at 3 months. DISCUSSION: Few differences in breastfeeding outcomes among WIC participants were attributable to delivery in a BFH. Results from this study inform policy about maternity practices impacting WIC breastfeeding outcomes. More study needed to determine the impact of BFH delivery on differences in breastfeeding outcomes between sub-groups of women.

Serving Summer Meals During the COVID-19 Pandemic: A Case Study of 2 Summer Food Service Program Sponsors in Maryland.

BACKGROUND: The Summer Food Service Program (SFSP) provides free and nutritious meals to children under age 18 during out-of-school times. During the COVID-19 pandemic, Maryland sponsors served over 9.5 million meals to children through an expanded version of the SFSP. This study aimed to explore and compare the factors that enabled 2 SFSP sponsors in Maryland to dramatically increase meals distribution during the pandemic. METHODS: Sponsors were selected based on their responses in the larger study and demographic characteristics of the area in which they served. Semi-structured in-depth interviews were conducted over Zoom-4 interviews with Sponsor A (3 interviews with the sponsor, 1 interview with their vendor) and 1 interview with Sponsor B. Qualitative data were analyzed inductively and deductively. Participation data from 2019 and 2020 were obtained from the Maryland State Department of Education and analyzed. RESULTS: Despite their differences in organization type and geographic region, they identified similar facilitators to their success-communication with the community and utilization of the United States Department of Agriculture-issued waivers. CONCLUSIONS: Strengthening community communication networks and permanently integrating more flexibility into regulation of the SFSP may increase meals participation during future out-of-school times.

Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland.

BACKGROUND: The Baby-Friendly Hospital Initiative is an effective intervention to support maternal practices around breastfeeding. However, adherence of hospitals to the Baby-Friendly 10 Steps, as determined from the perspective of women participating in the United States Special Supplemental Nutrition Program for Women, Infants, and Children, has not been assessed. RESEARCH AIMS: (1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months. METHODS: This study was a cross-sectional 2 group comparison, using prospective data collected through a self-report telephone survey and retrospective data gathered from participants' records. Women (N = 182) participating in four Maryland Special Supplemental Nutrition Program for Women, Infants and Children agencies were recruited. One hundred and eight (59%) participants delivered at designated Baby-Friendly Hospitals; 74 (41%) delivered in non-Baby-Friendly designated hospitals. Logistic regression models were utilized to determine the influence of perceived Step adherence on exclusive breastfeeding. RESULTS: Reported adherence to 10-Steps policies ranged from 10%-85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months. CONCLUSION: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

The Impact of Waivers on Summer Meal Participation in Maryland.

BACKGROUND: The Summer Food Service Program (SFSP) is a federally funded program that serves free, nutritious meals during the summer months. In 2019, 6 federal waivers that previously helped sponsors serve meals were rescinded. The purpose of this mixed methods study was to assess the impact of the waiver rescission on the experiences of SFSP sponsors in Maryland. METHODS: This study analyzed responses from Maryland SFSP sponsors in a quantitative online survey and linked meal participation data for 2018 and 2019 (n = 29) and in-depth interviews (n = 11) about their experiences serving summer meals. RESULTS: Most respondents reported that the waiver rescission significantly impacted their experience serving meals, including increases in workload, spending and staffing; reductions in meal types (eg, breakfast); fewer meals served; and changing closed sites to open. Sponsors expressed desire for the state to apply for waivers on behalf of all SFSP sponsors in future years. CONCLUSION: The federal rescission of USDA summer meals waivers created substantial barriers for sponsors. To address the issues created by policy decisions, school food authorities and other SFSP should continue to work with researchers and antihunger advocates to share their experiences in order to shape state programs and policies.

Role of the Elementary School Cafeteria Environment in Fruit, Vegetable, and Whole-Grain Consumption by 6- to 8-Year-Old Students.

OBJECTIVE: Examine how the physical cafeteria environment contributes to 6- to 8-year-olds' school food consumption. DESIGN: Cross-sectional observational study. Before-and-after lunch tray photos taken with iPads to capture food selection and consumption. SETTING: 10 New York City public elementary school cafeterias. PARTICIPANTS: A total of 382 students aged 6-8 years who ate lunch in the cafeteria on observation days. MAIN OUTCOME MEASURES: Fruit, vegetable, or whole-grain consumption. ANALYSIS: Pearson's chi-square and multivariate logistic regression assessed associations between cafeteria environmental factors (time to eat lunch, noise, and crowding) and vegetable, fruit, and/or whole-grain consumption with 95% confidence, adjusted for school-level demographics and clustered by school. RESULTS: Approximately 70% of students selected fruits, vegetables, and/or whole grains. When selected, consumption was 25%, 43%, and 57%, respectively. Longer time to eat lunch was associated with higher consumption of fruits (odds ratio [OR] = 2.0; 95% confidence interval [CI], 1.1-3.8; P = .02) and whole grains (OR = 2.1; 95% CI, 1.003-4.2; P < .05). Quieter cafeterias were associated with eating more vegetables (OR = 3.9; 95% CI, 1.8-8.4; P < .001) and whole grains (OR = 2.7; 95% CI, 2.6-4.7; P < .001). Less crowding was associated with eating more fruit (OR = 2.3; 95% CI, 1.03-5.3; P = .04) and whole grains (OR = 3.3; 95% CI, 1.9-5.6; P < .001). CONCLUSIONS AND IMPLICATIONS: Healthy food consumption by 6- to 8-year-old students is associated with cafeteria crowding, noise, and time to eat lunch. Implementing and enforcing changes to the cafeteria environment mandated by wellness policies may reduce plate waste.

Integrating Obstetrical Care and WIC Nutritional Services to Address Maternal Obesity and Postpartum Weight Retention.

OBJECTIVE: This pilot study evaluated a cost neutral, integrated Special Supplemental Nutrition Program for Women Infants and Children (WIC) and obstetrical service model designed to prevent postpartum weight retention in obese women. METHODS: A sample of women who received benefits from the Johns Hopkins (JH) WIC program and prenatal care from the JH Nutrition in Pregnancy Clinic, which provides obstetrical care for women with a BMI ≥ 30 kg/m2, participated in the WICNIP randomized clinical trial. Intervention participants received enhanced nutrition services and education at five visits and during one phone call between delivery and 6 months postpartum. Control participants received standard WIC services. Weight data was collected for all participants at multiple time points: pre-pregnancy, delivery, and postpartum at 4, 6 weeks, 4, and 6 months. Maternal socio-demographic factors, obesity class and the number of education contacts received were also recorded. RESULTS: Fifty-three African-American women were randomized into the intervention and control groups. Intervention participants retained significantly less gestational weight gain than control participants (3.0 ± 11.8 vs. 12.6 ± 20.4, p < 0.05). In both groups, participants with Class III obesity retained significantly less weight than participants in Classes I and II (p = 0.02). CONCLUSIONS FOR PRACTICE: An integrated WIC and obstetrical service model is feasible and can limit postpartum weight retention in obese women. Weight retention at 6 months postpartum between intervention and control participants was statistically significant. Further research should explore targeted interventions by obesity class to address weight retention for low-income, African American women who participate in WIC.

WIC Participation and Breastfeeding at 3 Months Postpartum.

Objectives Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower breastfeeding initiation and duration. This study examines breastfeeding-related factors among WIC participants and nonparticipants that might explain these previous findings. Methods Respondents to the 2007 Infant Feeding Practices Study II who were income-eligible for WIC were categorized as follows: no WIC participation (No-WIC); prenatal participation and infant entry while ≥60 % breastfeeding (WIC BF-high); prenatal participation and infant entry while <60 % breastfeeding (WIC BF-low). Percent breastfeeding was the number of breast milk feeds divided by the total number of liquid feeds. Using propensity scores, we matched WIC BF-high respondents to No-WIC respondents on demographic and breastfeeding factors. We used logistic regression to estimate the impact of WIC participation on breastfeeding at 3 months postpartum in the matched sample. Within-WIC differences were explored. Results Of 743 income-eligible respondents, 293 never enrolled in WIC, 230 were categorized as WIC BF-high, and 220 as WIC BF-low. Compared to matched No-WIC respondents, WIC BF-high respondents had increased odds of breastfeeding at 3 months, though this difference was not statistically significant (OR 1.92; 95 % CI 0.95-3.67; p value 0.07). WIC BF-high respondents were more similar on breastfeeding-related characteristics to No-WIC respondents than to WIC BF-low respondents. Conclusions for Practice Accounting for prenatal breastfeeding intentions and attitudes, we find no negative association between WIC participation and breastfeeding at 3 months postpartum. This is in contrast to prior studies, and highlights the importance of understanding within-WIC differences.

Are unmet breastfeeding expectations associated with maternal depressive symptoms?

OBJECTIVE: Most US women intend and initiate breastfeeding, yet many do not breastfeed as long as desired. Not meeting one's own prenatal expectations is a plausible mechanism for the previously observed association between lack of breastfeeding and postpartum depression (PPD). This study explored whether meeting prenatal expectations for exclusive breastfeeding was associated with PPD symptoms. METHODS: The 2005 Infant Feeding Practices Study II (IFPSII) followed US mothers, primarily white women with higher education and income, from midpregnancy to 1 year postpartum. Depressive symptoms were defined as Edinburgh Postnatal Depression Scale (EPDS) of 10 or higher, measured at 2 months postpartum. Logistic regression analysis evaluated the odds of maternal depressive symptoms as a function of meeting prenatal expectations for exclusive breastfeeding, accounting for breastfeeding behavior, demographics, and postnatal experiences. RESULTS: Among IFPSII participants, 1501 intended exclusive breastfeeding and completed the EPDS. At 2 months, 589 (39.2%) had met prenatal expectations for exclusive breastfeeding. EPDS was 10 or higher for 346 participants (23.1%). Adjusted odds of depressive symptoms were lower among women meeting prenatal exclusive breastfeeding expectations versus those who were not (odds ratio 0.71, 95% confidence interval 0.52-0.96). In subgroup analysis, there was no association between met expectations and depressive symptoms among women with lower incomes (<200% federal poverty level) or those intending mixed breast and formula feeding. CONCLUSIONS: Among middle- and higher-income women who intended exclusive breastfeeding, those meeting prenatal breastfeeding expectations reported fewer PPD symptoms at 2 months postpartum. Clinician understanding and support of maternal expectations may improve maternal mental health.

Met Expectations and Satisfaction with Duration: A Patient-Centered Evaluation of Breastfeeding Outcomes in the Infant Feeding Practices Study II.

BACKGROUND: Breastfeeding expectations predict breastfeeding duration. The extent to which expectations for duration are met remains unknown. OBJECTIVES: To evaluate prospective measures of expected breastfeeding duration, changes in expectations over time, and factors associated with meeting expectations. METHODS: The Infant Feeding Practices Study II followed women from late pregnancy to 1 year postpartum. Expected breastfeeding duration was assessed 5 times. Logistic regression identified factors associated with met prenatal expectations. Subgroup analysis compared met prenatal expectations to satisfaction with breastfeeding duration. RESULTS: One-year postpartum, 34.7% of 1802 participants had met prenatal expected breastfeeding duration, and 23.9% were still breastfeeding. Fifty-eight percent of women met expectations stated at 7 months postpartum. Modifiable risk factors associated with meeting prenatal expectations included early regular breast pump use (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.18-2.07). Return to work was negatively associated with met expectations (return by 6 weeks postpartum: OR, 0.48; 95% CI, 0.33-0.71; later return: OR, 0.73; 95% CI, 0.56-0.95). Among those who reported on satisfaction with duration (n = 1226), 40.4% were satisfied. Satisfaction was associated with meeting expectations (OR, 10.56; 95% CI, 7.67-14.55), but expectation and satisfaction measures were not equivalent. Elevated body mass index and depressive symptoms at 2 months postpartum were negatively associated with both measures. CONCLUSION: Most participants did not meet prenatal or postnatal expectations for breastfeeding duration and were unsatisfied with duration. However, at 12 months, more participants felt they had met their expectations and were satisfied with their breastfeeding duration than were actually breastfeeding. Therefore, women may perceive greater breastfeeding progress than suggested by Healthy People 2020 benchmarks.

Creativity and dementia: does artistic activity affect well-being beyond the art class?

The Alzheimer's Association's Memories in the Making (MIM) art activity program is intended to enhance the well-being of individuals who are living with dementia. Previous evaluations of MIM have found that participants show benefits on several well-being domains measured by the Greater Cincinnati Chapter Well-Being Observation Tool. The current study extended those findings by looking for evidence of carry-over effects beyond the temporal boundaries of MIM sessions. Additionally, this study evaluated key psychometric qualities of the assessment instrument. Seventy-six MIM participants with middle- to late-stage dementia were evaluated by interns and care facility staff at the beginning, middle and end of a 12-week MIM program. Interns focused on behavior within MIM sessions and staff rated functioning outside MIM sessions. Staff reported no significant changes in resident well-being across the 12-week program. Interns reported significant improvements from the beginning to middle and end of the program on five well-being domains. Psychometric analyses of the Greater Cincinnati Chapter Well-Being Observation Tool identified weaknesses in inter-rater reliability and found that the instrument measures two orthogonal factors--interpreted as 'Well-Being' and 'Ill-Being' - not the seven domains claimed. Quantitative evidence for the effectiveness of MIM is ambiguous, but anecdotal observations indicate that the program is beneficial for some participants, if only fleetingly.

Chronic stress and decreased physical exercise: impact on weight for African American women.

OBJECTIVE: African American women continue to have the highest prevalence of obesity in the United States and in the state of Maryland they are disproportionately affected by overweight and obesity. There are many contributing factors including chronic stress and the use of health behaviors such as physical exercise that play a role in increased weight for African American women. We examined the relationship of stress to weight and the role of physical exercise in African American paraprofessional women. DESIGN: Cross-sectional study SETTING: African American paraprofessionals were asked about their perspectives regarding association with chronic stress and physical exercise. RESULTS: The three most salient stressors for the women were finances (33%), work (28%) and family/friends (19%). Ninety percent of the women were overweight or obese. Significant predictors of increased BMI were lack of physical exercise (P = .004) and health compared to others (P = .006). Ethnic discrimination was a form of chronic stress (r = .319) but was not correlated with BMI (r = .095). Decreased physical exercise (P = .02) mediated the relationship between chronic stress and BMI. CONCLUSION: Findings regarding finance and work stress suggest the need for employers to consider the impact of job strain when implementing employee health programs to decrease stress and improve health. A focus on decreased physical exercise, unhealthy eating habits and misperceptions regarding increased risk for obesity related diseases with health status may be helpful to include in intervention strategies to decrease obesity for this population.

Early postpartum: a critical period in setting the path for breastfeeding success.

BACKGROUND: In the United States, most mothers who initiate breastfeeding will either stop or begin supplementing with formula before their infants are 3 months old. Routine breastfeeding education and support following hospital discharge are critical to breastfeeding success. The purpose of this article is to identify this critical period for supporting and reinforcing breastfeeding. METHODS: We will use data from participants enrolled in the Maryland State Program of the U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC). This cross-sectional study will explore whether breastfeeding patterns during the period between birth and postnatal WIC certification differ by participation in a local WIC agency that provides breastfeeding peer counselor support (PC) versus two comparison groups, the lactation consultant (LC) and standard care (SC) groups. RESULTS: During 2007, 33,582 infants were enrolled in the Maryland State WIC program. Infant breastfeeding status was categorized as exclusively breastfeeding, partially breastfeeding, or not breastfeeding. At certification, 30.4% of infants were breastfeeding, 25.3% had been breastfed but had stopped before certification in WIC, and 44.3% never breastfed. The breastfeeding initiation rate was higher for the PC group compared with the LC and SC groups (61.6% vs. 54.4% and 47.6%, respectively; p < 0.001). Participants in the PC group were more likely to certify as exclusively and partially breastfeeding compared with the LC and SC groups (36.0% vs. 24.8% and 25.3%, respectively; p < 0.001). CONCLUSION: Our analysis identifies a window of opportunity during which targeted contact with breastfeeding mothers could enhance longer-term breastfeeding rates.