Utilizing MOST frameworks and SMART designs for intervention research

Underreporting of Energy Intake Increases over Pregnancy: An Intensive Longitudinal Study of Women with Overweight and Obesity

(1) Background: Energy intake (EI) underreporting is a widespread problem of great relevance to public health, yet is poorly described among pregnant women. This study aimed to describe and predict error in self-reported EI across pregnancy among women with overweight or obesity. (2) Methods: Participants were from the Healthy Mom Zone study, an adaptive intervention to regulate gestational weight gain (GWG) tested in a feasibility RCT and followed women (n = 21) with body mass index (BMI) ≥25 from 8−12 weeks to ~36 weeks gestation. Mobile health technology was used to measure daily weight (Wi-Fi Smart Scale), physical activity (activity monitor), and self-reported EI (MyFitnessPal App). Estimated EI was back-calculated daily from measured weight and physical activity data. Associations between underreporting and gestational age, demographics, pre-pregnancy BMI, GWG, perceived stress, and eating behaviors were tested. (3) Results: On average, women were 30.7 years old and primiparous (62%); reporting error was −38% ± 26 (range: −134% (underreporting) to 97% (overreporting)), representing an ~1134 kcal daily underestimation of EI (1404 observations). Estimated (back-calculated), but not self-reported, EI increased across gestation (p < 0.0001). Higher pre-pregnancy BMI (p = 0.01) and weekly GWG (p = 0.0007) was associated with greater underreporting. Underreporting was lower when participants reported higher stress (p = 0.02) and emotional eating (p < 0.0001) compared with their own average. (4) Conclusions: These findings suggest systemic underreporting in pregnant women with elevated BMI using a popular mobile app to monitor diet. Advances in technology that allow estimation of EI from weight and physical activity data may provide more accurate dietary self-monitoring during pregnancy.

Applying the Multiphase Optimization Strategy for the Development of Optimized Interventions in Palliative Care

Recent systematic reviews and meta-analyses have reported positive benefit of multicomponent "bundled" palliative care interventions for patients and family caregivers while highlighting limitations in determining key elements and mechanisms of improvement. Traditional research approaches, such as the randomized controlled trial (RCT), typically treat interventions as "bundled" treatment packages, making it difficult to assess definitively which aspects of an intervention can be reduced or replaced or whether there are synergistic or antagonistic interactions between intervention components. Progressing toward palliative care interventions that are effective, efficient, and scalable will require new strategies and novel approaches. One such approach is the Multiphase Optimization Strategy (MOST), a framework informed by engineering principles, that uses a systematic process to empirically identify an intervention comprised of components that positively contribute to desired outcomes under real-life constraints. This article provides a brief overview and application of MOST and factorial trial design in palliative care research, including our insights from conducting a pilot factorial trial of an early palliative care intervention to enhance the decision support skills of advanced cancer family caregivers (Project CASCADE).

Factorial Designs Help to Understand How Psychological Therapy Works

A large amount of research time and resources are spent trying to develop or improve psychological therapies. However, treatment development is challenging and time-consuming, and the typical research process followed-a series of standard randomized controlled trials-is inefficient and sub-optimal for answering many important clinical research questions. In other areas of health research, recognition of these challenges has led to the development of sophisticated designs tailored to increase research efficiency and answer more targeted research questions about treatment mechanisms or optimal delivery. However, these innovations have largely not permeated into psychological treatment development research. There is a recognition of the need to understand how treatments work and what their active ingredients might be, and a call for the use of innovative trial designs to support such discovery. One approach to unpack the active ingredients and mechanisms of therapy is the factorial design as exemplified in the Multiphase Optimization Strategy (MOST) approach. The MOST design allows identification of the active components of a complex multi-component intervention (such as CBT) using a sophisticated factorial design, allowing the development of more efficient interventions and elucidating their mechanisms of action. The rationale, design, and potential advantages of this approach will be illustrated with reference to the IMPROVE-2 study, which conducts a fractional factorial design to investigate which elements (e.g., thought challenging, activity scheduling, compassion, relaxation, concreteness, functional analysis) within therapist-supported internet-delivered CBT are most effective at reducing symptoms of depression in 767 adults with major depression. By using this innovative approach, we can first begin to work out what components within the overall treatment package are most efficacious on average allowing us to build an overall more streamlined and potent therapy. This approach also has potential to distinguish the role of specific versus non-specific common treatment components within treatment.

Barriers to physical activity as moderators of intervention effects

The impact of interventions to increase physical activity (PA) may vary as a function of participants' barriers to PA. The aim of this paper is to determine whether individual barriers (demographic, physical health, psychological health, neighborhood factors, perceived barriers to PA, social support for PA) moderate treatment effects on increases in PA. Three treatment conditions tested the relative efficacy of a group-based PA intervention alone or supplemented by either personal or automated phone calls made between group meetings. From 2010 to 2012, 284 African American women (ages 40-65) living in the Chicago, IL, area were randomized to one of the three treatment conditions. Data collection occurred at baseline as well as 24 and 48 weeks after baseline. Moderation of intervention effects by barriers to PA were tested across four outcome measures (self-reported moderate-vigorous PA, self-reported walking, accelerometer steps, and aerobic fitness) using multilevel mixed-effects analyses. Significant condition by barrier interaction effects for the accelerometer steps outcome were found for material hardships, general health, depressive symptoms, neighborhood crime rate, and perceived barriers to PA. For aerobic fitness, intervention effects were moderated by material hardships and perceived pain. Increases in the outcome variables were greater for the conditions in which group sessions were supplemented with personal and/or automated calls. Among participants with greater barriers to PA, supplementing the intervention group meetings with between-session personal and/or automated phone calls may be an effective way to strengthen intervention effects. These results may inform the use of treatment supplements in the context of adaptive interventions.