Quality, features, and presence of behavior change techniques in mobile apps designed to improve physical activity in pregnant women: Systematic search and content analysis

Background: Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity. Objective: The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women. Methods: A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified. Results: Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality. Conclusions: Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women

Identification of Changes in Sleep Across Pregnancy and the Impact on Cardiometabolic Health and Energy Intake in Women with Obesity

This prospective, observational study investigated changes in sleep and the effect on energy intake, gestational weight gain, and cardiometabolic health across pregnancy in 52 healthy pregnant women with obesity. Habitual sleep was assessed by wrist-worn actigraphy (time spent in bed; TIB, total sleep time; TST, and sleep efficiency) in early (13(0)-15(6) weeks) and late (35(0)-36(6)) pregnancy. A change to habitual sleep was defined as change of one-half of the standard deviation of TIB and TST across six consecutive nights from early pregnancy. Energy intake and changes in weight, fasting glucose, insulin, and lipids across pregnancy were compared between women who changed sleep. During early pregnancy, TIB was 9:24±0:08h and varied by 1:37±0:07h across the six nights. TST and sleep efficiency significantly declined from early to late pregnancy (7:03±0:08h to 6:28±0:09h, p<0.001) and (76±0.1% to 71±0.2%, p<0.001), respectively. For women who increased TIB (n=11), fasting glucose decreased (−11.6±4.3%, p<0.01) across pregnancy and they had a trend towards decreased insulin (−57.8±33.5%; p=0.09) and HOMA-IR (−72.4±37.3%; p=0.06) compared to women who decreased TIB (n=13). Women who increased TIB had a significantly lower daily energy intake across pregnancy (−540±163 kcal; p<0.01) and tended to have less gestational weight gain (−147±88 g/week; p=0.10). Changes in TST did not affect plasma markers, energy intake or weight gain. The positive relationship between sleep and cardiometabolic health during pregnancy is explained in part by lower energy intake. We hypothesize lower energy intake is due to a prolonged overnight fast and a decrease in the time available for eating

Data from: Maternal pre-pregnancy weight status modifies the influence of PUFAs and inflammatory biomarkers in breastmilk on infant growth

Background: Human breastmilk contains pro- and anti-inflammatory compounds and hormones that can influence infant growth. However, little is known about the specific interrelationships between these compounds and whether their effects on infant growth may be influenced by pre-pregnancy weight status. Objective: The purpose of this novel, prospective cohort study was to assess the interrelationships between pro-inflammatory cytokines (TNF-α, IL-6), hormones (insulin, leptin) and PUFAs (n-6, n-3) in blood and breastmilk in early postpartum between women with normal BMI (Group 1, n=18; 18.5<BMI≤24.9 kg/m2) and with overweight/obesity (Group 2, n=15; BMI≥25.0 kg/m2) before pregnancy to determine if these components correlated to infant growth measures at age 4-8 weeks. Methods: Participants were robustly phenotyped along with their infants at 4-8 weeks postpartum. TNF-α, IL-6, insulin, leptin, and n-3 and n-6 PUFAs measured in blood and breastmilk and compared between pre-pregnancy BMI groups and with infant weight, length, head circumference and % fat mass. Results: Group 1 women had higher serum leptin (p<0.01) and breastmilk leptin (p<0.001) compared to Group 2. Other inflammatory markers, hormones, and total n-6, n-3 and n-6/n-3 ratio PUFAs were similar between pre-pregnancy BMI groups. No relationships were observed between whey inflammatory markers, hormones, PUFAs and growth measures in infants born to Group 2 women. However, TNF-α was positively related and, IL-6, leptin, insulin, total n-6, n-3 and n-6/n-3 PUFAs in whey breastmilk were negatively correlated to infant growth measures in infants born to Group 1 women (p<0.01). Conclusions: Pro-inflammatory qualities of breastmilk were associated with infant growth measures regardless of maternal pre-pregnancy BMI. However, infants born to women with overweight or obesity demonstrated less responsive growth to breastmilk contents. More studies are needed to assess longitudinal effects of this impact

Infant Feeding Varies Across Eating Behavior and Feeding Modalities in Mothers With Low Income

OBJECTIVE: To examine if eating behaviors in mothers with low income relate to attitudes toward infant feeding and whether associations differed between breastfeeding and formula-feeding mothers. DESIGN: Cross-sectional study. PARTICIPANTS: Forty postpartum women (aged ≥ 18 years, body mass index ≥ 25 and \u3c 40 kg/m2) in the Louisiana Women, Infants, and Children program participated in a telehealth postpartum intervention for health and weight loss. MAIN OUTCOME MEASURE(S): Maternal eating behaviors and infant feeding styles, assessed 6-8 weeks after birth (baseline) using validated questionnaires. ANALYSIS: Significance was detected using independent t tests, chi-square tests for independence, or linear models (P \u3c 0.05). RESULTS: Most mothers formula-fed (n = 27, 68%). In formula-feeding mothers, maternal disinhibition and perceived hunger were positively associated with restrictive infant feeding (β = 0.41, P \u3c0.001 and β = 0.41, P = 0.001, respectively). These relationships were significantly higher (Δ = -0.85, P = 0.006 and Δ = -0.59, P = 0.003, respectively) than among breastfeeding mothers. Comparatively, pressuring/overfeeding was lower in formula-feeding mothers than among breastfeeding mothers with dietary restraint (Δ slopes: 1.06, P = 0.02). CONCLUSIONS AND IMPLICATIONS: In this cohort of mothers with low income, maternal eating behavior was associated with infant feeding styles only when feeding modality was considered. Mothers may benefit from education on how their eating behaviors can influence their infants and children

Discrimination of wear and non-wear in infants using data from hip- and ankle-worn devices.

IntroductionA key component to analyzing wearable sensor data is identifying periods of non-wear. Traditionally, strings of consecutive zero counts (e.g. >60-minutes) are identified indicating periods of non-movement. The non-movement window length is then evaluated as wear or non-wear. Given that non-movement is not equivalent to non-wear, additional criteria should be evaluated to objectively identify periods of non-wear. Identifying non-wear is especially challenging in infants due to their sporadic movement, sleep frequency, and proportion of caregiver-generated movement.PurposeTo use hip- and ankle-worn ActiGraph wGT3X-BT (wGT3X-BT) data to identify non-wear in infants.MethodsFifteen infant participants [mean±SD; age, 8.7±1.7 weeks (range 5.4-11.3 weeks); 5.1±0.8 kg; 56.2±2.1 cm; n = 8 females] wore a wGT3X-BT on the hip and ankle. Criterion data were collected during two, 2-hour directly observed periods in the laboratory. Using raw 30 Hz acceleration data, a vector magnitude and the inclination angle of each individual axis were calculated before being averaged into 1-minute windows. Three decision tree models were developed using data from 1) hip only, 2) ankle only, and 3) hip and ankle combined.ResultsThe hip model classified 86.6% of all minutes (wear and non-wear) correctly (F1 = 75.5%) compared to the ankle model which classified 90.6% of all minutes correctly (F1 = 83.0%). The combined site model performed similarly to the ankle model and correctly classified 90.0% of all minutes (F1 = 80.8%).ConclusionThe similar performance between the ankle only model and the combined site model likely indicates that the features from the ankle device are more important for identifying non-wear in infants. Overall, this approach provides an advancement in the identification of device wear status using wearable sensor data in infants

Maternal mindful eating as a target for improving metabolic outcomes in pregnant women with obesity.

BackgroundMaternal diet and eating behaviors have the potential to influence the metabolic milieu in pregnancies complicated by obesity, with implications for the developmental programming of offspring obesity. Emerging evidence suggests that mindfulness during eating may influence metabolic health in non-pregnant populations, but its effects in the context of pregnancy is less well understood. This study explored the individual and combined effects of mindful eating and diet quality on metabolic outcomes among pregnant women with obesity.MethodsIn 46 pregnant women (body mas index &gt;30 kg/m2) enrolled in the MomEE observational study, mindful eating (Mindful Eating Questionnaire, MEQ) and energy-adjusted dietary inflammatory index (DII, from 7 days of food photography) was assessed at two time points and the mean pregnancy values computed. Rate of gestational weight gain (GWG) and fat mass gain per week were determined from measured weight and body composition using a three-compartment method, respectively, at each assessment. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and ghrelin concentrations were determined from fasting blood samples in late gestation (35-37 weeks). Linear regression was used to examine the association of the MEQ and its subscales (where higher values indicate more mindful eating) with metabolic outcomes, adjusting for covariates: maternal age, pregravid body mass index, race, parity, DII. The effects of the MEQ*DII interaction was also tested.ResultsTotal MEQ scores were not associated with rate of weight or fat mass gain, although greater distracted eating behavior was associated with greater adiposity gain (weight and fat mass). Mindful eating was inversely associated with insulin resistance, although this was attenuated to non-significance after additional adjustment for GWG. Total MEQ and the external eating subscale was significantly inversely associated with fasted ghrelin, such that less tendency to eat under the influence of external cues was associated with lower ghrelin concentrations. After false discovery rate adjustment for multiple testing, only the association of the total MEQ and external eating subscale with ghrelin levels trended towards significance. The DII was not associated with MEQ scores or outcome variables, nor did it moderate the effect of MEQ on any of the outcomes.ConclusionThis study generates early evidence to suggest that mindful eating holds potential as a tool to improve metabolic health outcomes in pregnant women with obesity, although further research is required on this topic. Prenatal lifestyle interventions should consider including mindfulness during eating to determine its efficacy for reducing adverse pregnancy and offspring health outcomes associated with maternal obesity

Behavioral Determinants of Objectively Assessed Diet Quality in Obese Pregnancy

Interventions to promote healthy pregnancy in women with obesity by improving diet quality have been widely unsuccessful. We hypothesized that diet quality is determined by eating behaviors, but evidence in women with obesity is lacking. We evaluated diet quality and eating behavior in 56 women with obesity (mean &plusmn; SEM, 36.7 &plusmn; 0.7 kg/m2, 46% White, 50% nulliparous) early in pregnancy (14.9 &plusmn; 0.1 weeks). Diet quality was objectively assessed with food photography over six days and defined by Healthy Eating Index. Eating behaviors were assessed by validated questionnaires. Women reported consuming diets high in fat (38 &plusmn; 1% of energy) and the HEI was considered &ldquo;poor&rdquo; on average (46.7 &plusmn; 1.3), and for 71% of women. Diet quality was independently associated with education level (p = 0.01), food cravings (p &lt; 0.01), and awareness towards eating (p = 0.01). Cravings for sweets and fast foods were positively correlated with respective intakes of these foods (p &lt; 0.01 and p = 0.04, respectively), whereas cravings for fruits and vegetables did not relate to diet intake. We provide evidence of the determinants of poor diet quality in pregnant women with obesity. Based on this observational study, strategies to improve diet quality and pregnancy outcomes are to satisfy cravings for healthy snacks and foods, and to promote awareness towards eating behaviors

Impact of COVID-19 Stay-at-Home Orders on Health Behaviors and Anxiety in Black and White Americans

BACKGROUND: In the United States (US), the incidence and severity of COVID-19 infections, hospitalizations, and deaths are higher in Black compared to White residents. Systemic inequities and differences in health behaviors may contribute to disparities in COVID-19 health outcomes. The aim of this study was to examine the impact of COVID-19 stay-at-home orders on changes in health behaviors and anxiety in Black and White adults residing in the US. METHODS: Beginning April 2020, the Pennington Biomedical Research Center COVID-19 Health Behaviors Study collected information on changes to employment, income, diet, physical activity, anxiety, and sleep patterns through a global online survey. RESULTS: Of 4542 survey respondents in the US, 7% identified as Black and 93% as White. Prior to the COVID-19 stay-at-home orders, a greater proportion of Blacks compared to Whites reported earning \u3c US$50,000 per year (p \u3c 0.0001). A greater proportion of Blacks reported being laid off, working fewer hours, and working from home following COVID-19 stay-at-home orders (p \u3c 0.0001 for all). In the overall sample, eating behaviors improved, physical activity decreased, sleep time prolonged, and anxiety heightened following COVID-19 stay-at-home orders (p \u3c 0.01 for all), which were universal between Black and White respondents (p ≥ 0.315 for all). CONCLUSIONS: This study highlights the disproportionate changes to employment and income in Blacks, with no differential impact on health behaviors and anxiety compared to Whites due to COVID-19 stay-at-home orders. As the COVID-19 pandemic continues, disproportionate changes to employment and income status may widen among Blacks and Whites, which may influence health behaviors and anxiety

Metabolic inflexibility in women with PCOS is similar to women with type 2 diabetes

Abstract Background An ability to switch between primarily oxidizing fat in the fasted state to carbohydrate in the fed state, termed metabolic flexibility, is associated with insulin sensitivity. Metabolic flexibility has been explored previously in women with polycystic ovary syndrome (PCOS), yet the independent or synergistic contributions of androgen excess and/or insulin resistance is not yet known. Therefore, the purpose of this article was to characterize metabolic flexibility in women with PCOS compared to women of normal BMI, obesity, or type 2 diabetes (T2DM). Methods Eighty-six weight-stable women; thirty with either PCOS (n = 30), or fifty-six with obesity (n = 12), T2DM (n = 27), or normal BMI (n = 17) underwent a hyperinsulinemic euglycemic clamp and indirect calorimetry to measure insulin sensitivity and substrate oxidation via indirect calorimetry, respectively. Results All analyses were adjusted for differences in age, ethnicity, and BMI between groups. Women with PCOS were less metabolically flexible compared to healthy women with obesity (p < 0.0001), normal BMI (p < 0.0001), but after controlling for glucose disposal rate, were similar to women with T2DM (p = 0.99). When dividing women with PCOS above and below the mean cutoff for insulin resistance, the insulin resistant women with PCOS had lower rates of non-oxidative glucose metabolism (p = 0.0001), higher levels of percent free testosterone (p = 0.04), a higher free androgen index (p = 0.006), more visceral adipose tissue (p = 0.02), and were less metabolically flexible (p = 0.007). Conclusions Women with T2DM were as metabolically inflexible as women with PCOS. When stratifying women with PCOS into those who are metabolically flexible and inflexible, the women who are inflexible display greater amounts of visceral fat and androgen excess. The inability to alter substrate use given the physiological stimulus may lead to subsequent increases in adiposity in women with PCOS thereby further worsening the insulin resistance. Trial registration number Clinical Trials.gov, NCT01482286. Registered 30 November 2011

Evidence-based recommendations for energy intake in pregnant women with obesity.

BACKGROUND: In women with obesity, excess gestational weight gain (≥270 g/week) occurs in two out of three pregnancies and contributes to metabolic impairments in both mother and baby. To improve obstetrical care, objectively assessed information on energy balance is urgently needed. The objective of this study was to characterize determinants of gestational weight gain in women with obesity. METHODS: This was a prospective, observational study of pregnant women with obesity. The primary outcome was energy intake calculated by the energy intake-balance method. Energy expenditure was measured by doubly-labeled water and whole-room indirect calorimetry and body composition as 3-compartment model by air displacement plethysmography and isotope dilution in early (13-16 weeks) and late pregnancy (35-37 weeks). RESULTS: In pregnant women with obesity (n=54), recommended weight gain (n=8, 15%) during the second and third trimesters was achieved when energy intake was 125±52 kcal/d less than energy expenditure. In contrast, women with excess weight gain (67%) consumed 186±29 kcal/d more than they expended (P CONCLUSIONS: We here provide the first evidence-based recommendations for energy intake in pregnant women with obesity. Contrary to current recommendations, energy intake should not exceed energy expenditure. FUNDING: This study was funded by the National Institutes of Health (R01DK099175; Redman, U54GM104940 and P30DK072476; Core support). TRIAL REGISTRATION: clinicaltrials.gov: NCT01954342