Interventions to Manage Weight During the Transition to
Motherhood: Translating to Clinical Care
Exercise Psychology Laboratory
Annual Meeting of the Society of Behavioral Medicine
April 2 2016
Dr. Danielle Symons Downs, Professor of Kinesiology and OBGYN
The Pennsylvania State University
Symposium Objectives
• Describe a preconceptional and
prenatal intervention to manage
perinatal weight gain
• Highlight key lessons learned on
building effective communications
with clinics and providers
• Recommendations for translating
research to practice
Exercise Psychology Laboratory
Annual Meeting of the Society of Behavioral Medicine
April 2 2016
The Problem
Exercise Psychology Laboratory
(Flegal et al., 2010 – JAMA, 303; 235-241)
(Haugen et al., 2014 – BMC Preg & Childbirth, 14; 201-211)
• Most US women enter pregnancy
– OW 45%, OB 30%
• Average maternal weight at time
of 1st pregnancy increased
– > 20% since 1980
– 25% women weigh > 200 pounds
• GWG in excess of guidelines
– OW 70%, OB 60%
• Maternal and fetal complications
(CDCP, 2009; IOM, 2009; Linne et al., 2004; NRC, 2007)
The Problem
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• Limited effective strategies
– reduce obesity before pregnancy
– limit GWG in pregnancy
– lose weight after pregnancy
• Transitional approach needed
Preconceptional Perinatal Postpartum
Perinatal Period
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Perinatal Period
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• Ideal time for intervention
• Evidence for interventions to reduce
risk of high GWG
– diet only, diet + exercise interventions
can reduce risks by up to 20%
• Effects limited to normal weight
women
– OW/OB women exercise less and have
trouble adhering to diet
recommendations
(Muktabhant et al., 2015)
(Streuling et al., 2011; Sui et al., 2012; Choi et al., 2013)
Goal of R01
Weisman, C. S., Hillemeier, M. M., Symons Downs, D., Chuang, C. H., & Dyer, A. M. (2010).
Preconception predictors of weight gain during pregnancy: Prospective findings from the Central
Pennsylvania Women’s Health Study. Women’s Health Issues, 20, 126-132.
• Develop and test individually-tailored, adaptive intervention
to manage GWG in OW/OB pregnant women
• adapt dosages to unique needs of OW/OB women
• utilize m-Health technology for self-monitoring
• data visualization to understand relationships with HE/EX and GWG
• dynamical systems modeling to optimize intervention efficiency/effectiveness
Exercise Psychology Laboratory
1R01HL119245-01
(PI, Dr. Downs)
Intervention Components
Exercise Psychology LaboratoryComponents: Evidence-based from model programs (DPP, Look AHEAD,
past GWG interventions, and PI research on promoting healthy behaviors in
pregnancy with the Theory of Planned Behavior (NIDDK 07586702).
1R01HL119245-01
Education• GWG/nutrition/EX guidelines
• GWG plotting
• Energy density, portion size, etc.
• EX benefits, safety, strategies
Goal-Setting• Principles, implementation intentions
• Healthy eating/EX plans
• Problem-solving/weekly feedback
Self-Monitoring
• Behaviors, feedback, overcoming
barriers
Active Learning
• Healthy eating/EX sessions
Adaptive Dosages
Exercise Psychology Laboratory
1R01HL119245-01
Decision Rule: evaluate GWG every 3-4 weeksAdapt intervention (step-up) if > GWG goal
Step-up 5
+
Step-up 4
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Step-up 4
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Step-up 3
+
Step-up 3
+
Step-up 3
+
Step-up 2
+
Step-up 2
+
Step-up 2
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Step-up 2
+
Step-Up 1
+
Step-Up 1
+
Step-Up 1
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Step-Up 1
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Step-Up 1
+
Baseline Baseline Baseline Baseline Baseline Baseline
More intensive
as she is “less
controlled” with
managing GWG
(PI, Dr. Downs)
Study 1 Feasibility Results
• Identified threshold of “too much intervention”
– Mmst intensive dosage in the pilot was too much so we made modifications
• Protocol modifications
– revised screening protocol (e.g., wider BMI range, excluded smokers)
– increased efforts to recruit women into study sooner (~6-8 weeks gestation)
• Assessment Protocol
– dropped Supertracker and ASA-24 – women greatly disliked
– back-calculated method for EI vs. assessed EI
Exercise Psychology Laboratory
1R01HL119245-01
Currently in progress with Study 2 – fully adaptive intervention to manage
GWG in OW/OB pregnant women (RCT design)
Collaboration with Geisinger Health Systems
Exercise Psychology Laboratory
• Translation…
• Improve OB care by managing GWG among
high risk women to:
– improve patient experience
– reduce maternal-fetal complications
– reduce prenatal and NICU costs
• Geisinger Quality Fund Proposal
Preconception Period
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Call for Paradigm Shift
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CDCP (2005): comprehensive
strategy for improving
women’s preconception health
“ensure that all U.S. women of childbearing age receive preconception
care services, screening, health promotion, and interventions that will
enable them to enter pregnancy in optimal health”
CePAWHS Phase I
• Prospective cohort study
• Population-based surveys
of reproductive women
– N = 2,002
• Goal: to establish
prevalence of risk factors
and identify subgroups at
greatest risk preterm birth
Exercise Psychology Laboratory
28-county region with 3 mid-sized cities
(Harrisburg, York, Lancaster) and a large rural
population including from small towns and
isolated rural areas
Weisman, C. S., Hillemeier, M. M., Chase, G. A., Dyer, A. M., Baker, S. A., Feinberg, M. Symons Downs,
D., Parrott, R. L., Cecil, H. K., Botti, J. J., MacNeill, C., Chuang, C. H., & Yost, B. (2006). Preconceptional health:
Risks of adverse pregnancy outcomes by reproductive life stage in the Central Pennsylvania women's health
study (CePAWHS). Women's Health Issues, 16(4), 216-226.
CePAWHS Preconception Predictors of GWG
Exercise Psychology Laboratory
• Examined preconception predictors (weight status, age, parity,
health behaviors) of GWG
• 1,420 (n=103) not pregnant at baseline but gave birth by 2 yr FU
• Found:
• average GWG 33 lbs; 51% exceeded IOM GWG guidelines
• preconception overweight = 3-fold increased odds of high GWG
• preconception PA (meet guidelines) = reduced odds (p=.06)
Weisman, C. S., Hillemeier, M. M., Symons Downs, D., Chuang, C. H., & Dyer, A. M. (2010). Preconception
predictors of weight gain during pregnancy: Prospective findings from the Central Pennsylvania Women’s Health
Study. Women’s Health Issues, 20, 126-132.
Key Finding: preconception weight
status and PA levels are prime targets
for intervention to reduce high GWGWeight
Status
Pounds
Underweight 28-40
Normal 25-35
Overweight 15-25
Obese 11-20
BMI-Specific GWG Goals
CePAWHS Phase 2
• Community-delivered, group
intervention led by trained
facilitators
• Targeted outcomes:
– knowledge, self-efficacy, intention,
behavior change, and health status
improvement
• Behaviors:
– stress, nutrition, PA,
tobacco/alcohol exposure,
gynecological infections, preparing
for pregnancy
Exercise Psychology Laboratory
Symons Downs, D., Feinberg M., Hillemeier, M. H., Weisman, C. S., Chase, G. A., Chuang, C. H., Parrott, R., &
Francis, L. A. (2009). Design of the Central Pennsylvania Women’s Health Study (CePAWHS) strong healthy
women intervention: Improving preconceptional health. Maternal and Child Health Journal, 13(1), 18-28.
CePAWHS Strong Health Women RCT
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Recruitment (n=692)
Baseline Risk Assessment
Random Assignment
Intervention (n=473)
six (2 hr sessions)
over 12 weeks
Follow-up Risk Assessment (n=362)
Follow-up telephone surveys
at 6 and 12 months
Control (n=219)
Symons Downs et al. (2009). Maternal and Child Health Journal, 13(1), 18-28.
Pre-Post Intervention Results
• Intervention group significantly more
likely than controls to report higher
– self-efficacy for eating healthy foods
– intention to eat healthy/engage in PA
– frequency of reading food labels
– PA consistent with guidelines
– daily use of multivitamin with folic acid
• Expected direction but N/S
– weight, waist circum, non-fasting blood
glucose, lipids
• Dose-response
– more PA, attended more sessions
Exercise Psychology Laboratory
Hillemeier, M. M., Symons Downs, D., Feinberg, M. E., Weisman, C. S., Chuang, C. H., Parrott, R., Velott, D.,
Francis, L. A., Baker, S. A., Dyer, A., & Chinchilli, V. M. (2009). Improving women’s preconceptional health:
Findings from a randomized trial of the Strong Healthy Women intervention in the Central Pennsylvania
Women’s Health Study. Women’s Health Issues, 18S, S87-S96.
Food portions
Nutrition
Labels
Meet PA
Guidelines
SHW 12-Month Follow-up
• Examined 12-month effects of
SHW intervention on BMI and
weight (n=362)
• Found:
– intervention women had
significantly lower weight & BMI
than controls
– 45 women became pregnant …
Exercise Psychology Laboratory
Weisman, C. S., Hillemeier, M. M., Symons Downs, D., Feinberg, M. E., Chuang, C. H., Botti, J. J.,
& Dyer, A. M. (2011). Improving women’s preconceptional health: Long-term effects of the Strong
Healthy Women behavior change intervention in the Central Pennsylvania Women’s Health Study.
Women’s Health Issues, 21, 265-271.
SHW Preconception Intervention
Weisman, C. S., Hillemeier, M. M., Symons Downs, D., Chuang, C. H., & Dyer, A. M. (2010).
Preconception predictors of weight gain during pregnancy: Prospective findings from the Central
Pennsylvania Women’s Health Study. Women’s Health Issues, 20, 126-132.Exercise Psychology Laboratory
Weisman, C. S., Hillemeier, M. M., Symons Downs, D., Feinberg, M. E., Chuang, C. H., Botti, J. J.,
& Dyer, A. M. (2011). Improving women’s preconceptional health: Long-term effects of the Strong
Healthy Women behavior change intervention in the Central Pennsylvania Women’s Health Study.
Women’s Health Issues, 21, 265-271.
Preg at follow-up
(n = 45)
INT CON p
GWG (pounds) 23.4 41.4 .02
GWG (controlling for
prepreg obesity*)
23.8 34.2 .13
GWG exceeded IOM
guidelines**
43% 56% .65
*Obesity defined as BMI > 30.0.
** Mother’s GWG exceeded IOM (2009) guidelines for pre-pregnancy BMI category.
Among those who became pregnant during the follow-up (n = 45) …
SHW preconception intervention appears to also
help women manage their GWG, although rates
still exceed IOM guidelines for OW/OB women
SMART SHW
• Pilot study to extend SHW to
integrate smartphones to deliver
portions of the content
• Develop weight management
content
• Feasibility results
– OW/OB women – good user
acceptability of phone-based
delivery
– salient beliefs
Exercise Psychology Laboratory
Penn State CTSI Community Engagement Funding
Lessons Learned
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Lessons Learned & Recommendations
Exercise Psychology Laboratory
• Recruiting preconception and pregnant
women
• community and clinic methods
• Community and clinic collaborations
• establishing relationships: clinics, Family
Health Council
• Work toward overcoming challenges
• getting women focused on preconception
health!!
• changes to perinatal care (more focus on
mom’s health)
• consistency in rec’s for OW/OB women
(weight loss before pregnancy?)
• translating intensive interventions to
effective practice
Collaborative Team
• Dr. Jennifer S. Savage, Center for Childhood Obesity Research and Department
of Nutritional Sciences, The Pennsylvania State University
• Dr. Lisa Bailey-Davis, Geisinger Health Systems
• Dr. Daniel E. Rivera, Control Systems Engineering Laboratory, School for
Engineering of Matter, Transport, and Energy, Arizona State University
• Drs. Linda Collins, Joshua Smyth, Barbara Rolls, Rick Legro, Jamey Pauli, Erica
Rauff, Diana Thomas, Yueng Dong, Brandi Rollins, Katie Balantekin
• Abigail Pauley, Lindsey Hess, Allen Kunselman, Courtenay Devlin, Penghong
Guo, Krista Leonard, Emily Hohman
Exercise Psychology Laboratory
Dr. Danielle Symons Downs
mailto:[email protected]
Funding
• Support for this work has been provided by the Office of Behavioral and
Social Sciences Research (OBSSR) of the National Institutes of Health, the
National Institute on Drug Abuse (NIDA), National Heart, Lung, and Blood
Institute (NHLBI) through grants R21 DA024266 (roadmap), K25 DA021173,
R01 HL119245-01, R56HL126799-01, USDA NIFA (#2011-67001-30117
Program A2121 Childhood Obesity Prevention Training Program), and PSU
State Social Science Research Institute, Pennsylvania Department of
Health, and Geisinger Health Systems
Exercise Psychology Laboratory
Dr. Danielle Symons Downs
mailto:[email protected]