1
|
Ioannou E, Humphreys H, Homer C, Purvis A. Preventing Type 2 Diabetes after Gestational Diabetes: A Systematic Review Mapping Physical Activity Components using the Socio-Ecological Model. Matern Child Health J 2024; 28:1354-1379. [PMID: 38829517 PMCID: PMC11269493 DOI: 10.1007/s10995-024-03948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Gestational diabetes commonly occurs during pregnancy and increases lifetime risk of type 2 diabetes following pregnancy. Engaging in physical activity postnatally can reduce this subsequent risk. Interventions aiming to increase physical activity after gestational diabetes may not address the wide range of post-pregnancy barriers. A socio-ecological approach highlights the need to include multi-level factors such as social, community and organisational factors. The aim of the review was to map intervention components to prevent type 2 diabetes after gestational diabetes using the socio-ecological model as a framework and investigate how physical activity changes align with different intervention components utilised. METHODS Eligible studies included any study type within 5 years of a gestational diabetes diagnosis and targeted physical activity. A systematic search of MEDLINE, Cochrane Library, Web of Science, CINAHL Complete, and Scopus was conducted in October 2022. Results were categorised based on whether findings demonstrated no increases, non-statistically significant increases or statistically significant increases in physical activity. RESULTS Forty-eight studies were included (37 different interventions). Thirty-eight studies were assessed as "adequate" quality, only two studies were "good" quality, and the remaining were limited quality. Mixed physical activity outcomes were observed across components used at the intrapersonal level, with components across other levels of the socio-ecological model showing more increases in physical activity. Intervention components within the social and organisational levels, for example childcare provision, providing group-based sessions and offering remote delivery, were more often present in interventions with physical activity increases. CONCLUSIONS FOR PRACTICE Future interventions targeting physical activity after gestational diabetes should aim to include social and organisational-level components in their intervention design. This systematic review was registered in PROSPERO (ID: CRD42021272044).
Collapse
Affiliation(s)
- Elysa Ioannou
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK.
| | - Helen Humphreys
- Centre for Behavioural Science and Applied Psychology (CeBSAP), Sheffield Hallam University, Sheffield, UK
| | - Catherine Homer
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Alison Purvis
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK
| |
Collapse
|
2
|
Nicklas JM, Pyle L, Soares A, Leiferman JA, Bull SS, Tong S, Caldwell AE, Santoro N, Barbour LA. The Fit After Baby randomized controlled trial: An mHealth postpartum lifestyle intervention for women with elevated cardiometabolic risk. PLoS One 2024; 19:e0296244. [PMID: 38194421 PMCID: PMC10775990 DOI: 10.1371/journal.pone.0296244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/03/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Postpartum women with overweight/obesity and a history of adverse pregnancy outcomes are at elevated risk for cardiometabolic disease. Postpartum weight loss and lifestyle changes can decrease these risks, yet traditional face-to-face interventions often fail. We adapted the Diabetes Prevention Program into a theory-based mobile health (mHealth) program called Fit After Baby (FAB) and tested FAB in a randomized controlled trial. METHODS The FAB program provided 12 weeks of daily evidence-based content, facilitated tracking of weight, diet, and activity, and included weekly coaching and gamification with points and rewards. We randomized women at 6 weeks postpartum 2:1 to FAB or to the publicly available Text4baby (T4B) app (active control). We measured weight and administered behavioral questionnaires at 6 weeks, and 6 and 12 months postpartum, and collected app user data. RESULTS 81 eligible women participated (77% White, 2% Asian, 15% Black, with 23% Hispanic), mean baseline BMI 32±5 kg/m2 and age 31±5 years. FAB participants logged into the app a median of 51/84 (IQR 25,71) days, wore activity trackers 66/84 (IQR 43,84) days, logged weight 17 times (IQR 11,24), and did coach check-ins 5.5/12 (IQR 4,9) weeks. The COVID-19 pandemic interrupted data collection for the primary 12-month endpoint, and impacted diet, physical activity, and body weight for many participants. At 12 months postpartum women in the FAB group lost 2.8 kg [95% CI -4.2,-1.4] from baseline compared to a loss of 1.8 kg [95% CI -3.8,+0.3] in the T4B group (p = 0.42 for the difference between groups). In 60 women who reached 12 months postpartum before the onset of the COVID-19 pandemic, women randomized to FAB lost 4.3 kg [95% CI -6.0,-2.6] compared to loss in the control group of 1.3 kg [95% CI -3.7,+1.1] (p = 0.0451 for the difference between groups). CONCLUSIONS There were no significant differences between groups for postpartum weight loss for the entire study population. Among those unaffected by the COVID pandemic, women randomized to the FAB program lost significantly more weight than those randomized to the T4B program. The mHealth FAB program demonstrated a substantial level of engagement. Given the scalability and potential public health impact of the FAB program, the efficacy for decreasing cardiometabolic risk by increasing postpartum weight loss should be tested in a larger trial.
Collapse
Affiliation(s)
- Jacinda M. Nicklas
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States of America
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado, United States of America
| | - Andrey Soares
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Jennifer A. Leiferman
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, Colorado, United States of America
| | - Sheana S. Bull
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, Colorado, United States of America
| | - Suhong Tong
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado, United States of America
| | - Ann E. Caldwell
- Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States of America
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility & Reproductive Sciences, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Linda A. Barbour
- Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States of America
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| |
Collapse
|
3
|
Wagner KA, St Laurent CW, Pekow P, Marcus B, Rosal MC, Braun B, Manson JE, Whitcomb BW, Sievert LL, Chasan-Taber L. The Impact of a Lifestyle Intervention on Postpartum Cardiometabolic Risk Factors Among Hispanic Women With Abnormal Glucose Tolerance During Pregnancy: Secondary Analysis of a Randomized Trial. J Phys Act Health 2024; 21:40-50. [PMID: 37890839 DOI: 10.1123/jpah.2023-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Women with abnormal glucose tolerance during pregnancy are at risk for cardiovascular disease (CVD), with higher rates among Hispanics. However, studies on the impact of lifestyle interventions on postpartum CVD profiles are sparse. METHODS This is a secondary analysis of a controlled trial among a subsample of Hispanic women with abnormal glucose tolerance participating in Estudió PARTO (Project Aiming to Reduce Type twO diabetes; mean age = 28.2 y, SD: 5.8) who were randomized to a culturally modified Lifestyle intervention (n = 45) or a comparison Health and Wellness intervention (n = 55). Primary endpoints were biomarkers of cardiovascular risk (lipids, C-reactive protein, fetuin-A, and albumin-to-creatinine ratio) and insulin resistance (fasting insulin, glucose, HbA1c, homeostasis model assessment, leptin, tumor necrosis factor-alpha, and adiponectin) measured at baseline (6-wk postpartum) and 6 and 12 months. RESULTS In intent-to-treat analyses, there were no significant differences in changes in biomarkers of CVD risk or insulin resistance over the postpartum year. In prespecified sensitivity analyses, women adherent with the Lifestyle Intervention had more favorable improvements in insulin (intervention effect = -4.87, SE: 1.93, P = .01) and HOMA-IR (intervention effect = -1.15, SE: 0.53, P = .03) compared with the Health and Wellness arm. In pooled analyses, regardless of intervention arm, women with higher postpartum sports/exercise had greater increase in HDL-cholesterol (intervention effect = 6.99, SE: 1.72, P = .0001). CONCLUSIONS In this randomized controlled trial among Hispanic women with abnormal glucose tolerance, we did not observe a significant effect on postpartum biomarkers of CVD risk or insulin resistance. Women adherent to the intervention had more favorable changes in insulin and HOMA-IR.
Collapse
Affiliation(s)
- Kathryn A Wagner
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | - Christine W St Laurent
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Penelope Pekow
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | - Bess Marcus
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Population & Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Barry Braun
- Department of Health & Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Joann E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian W Whitcomb
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | - Lisa Chasan-Taber
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| |
Collapse
|
4
|
Horwitz MEM, Edwards CV, Athavale P, McCloskey L, Cabral HJ, Benjamin EJ, Handley MA. The STAR-MAMA RCT: Bilingual Mobile Health Coaching for Postpartum Weight Loss. Am J Prev Med 2023; 65:596-607. [PMID: 37028566 DOI: 10.1016/j.amepre.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION Gestational diabetes and overweight during pregnancy are associated with future type 2 diabetes. Postpartum weight loss can reduce diabetes risk. However, effective interventions for postpartum weight loss are lacking, in particular for Latina populations, despite their disproportionate burdens of gestational diabetes, overweight, and diabetes. STUDY DESIGN This was a community-based RCT. SETTING/PARTICIPANTS Researchers recruited pregnant individuals with gestational diabetes or BMI>25 kg/m2 from safety-net health care settings and Women, Infants, and Children offices in Northern California in 2014-2018. Of 180 individuals randomized to intervention (n=89) or control (n=91), 78% identified as Latina, 61% were primarily Spanish speaking, and 76% perceived their diabetes risk to be low. INTERVENTION The intervention consisted of a 5-month postpartum telephone-based health coaching intervention delivered in English or Spanish. MAIN OUTCOME MEASURES Data were collected through surveys at enrollment and 9-12 months after delivery and chart review up to 12 months after delivery. The primary outcome, weight change from prepregnancy to 9-12 months after delivery, was compared between the groups, overall and within strata defined a priori according to language (Spanish or English) and diabetes risk perception (none/slight or moderate/high). RESULTS The intent-to-treat estimated intervention effect was +0.7 kg (95% CI= -2.4 kg, +3.8 kg; p=0.67). In stratified analyses, intervention effects remained nonsignificant but varied in direction: effects were favorable among English speakers and those with higher perceived diabetes risk, and unfavorable among Spanish speakers and those with lower perceived risk. Analyses were conducted in 2021-2022. CONCLUSIONS A postpartum health coaching intervention, designed for low-income Latina women at increased risk for diabetes, did not reduce postpartum weight gain. Intervention effects were nonsignificantly more favorable among English speakers versus Spanish speakers, and among those who perceived their diabetes risk to be high versus low. TRIAL REGISTRATION This study is registered at www. CLINICALTRIALS gov NCT02240420.
Collapse
Affiliation(s)
- Mara E Murray Horwitz
- Women's Health Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.
| | - Camille V Edwards
- Section of Hematology/Oncology, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Priyanka Athavale
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California
| | - Lois McCloskey
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Margaret A Handley
- Department of Epidemiology, School of Medicine, University of California San Francisco, San Francisco, California; Department of Biostatistics, School of Medicine, University of California San Francisco, San Francisco, California; Partnerships for Research in Implementation Science for Equity (PRISE) Center, University of California San Francisco, San Francisco, California
| |
Collapse
|
5
|
Kumari A, Ranjan P, Vikram NK, Kaur D, Balsarkar G, Malhotra A, Puri M, Batra A, Madan J, Tyagi S, Guleria K, Dabral A, Sarkar S, Nigam A, Anwar W, Kamath S, Bhatla N, Kumari SS, Kumar R, Choranur A, Venkataraman S, Kaur T, Rathore AM, Kaloiya GS, Prakash A, Tiwaskar M, Verma A, Singh R, Sharma KA, Baitha U, Tewary K, Misra A, Guleria R. Evidence and consensus-based clinical practice guideline for the management of obesity and overweight in postpartum women: An AIIMS-DST initiative. J Family Med Prim Care 2023; 12:812-855. [PMID: 37448937 PMCID: PMC10336934 DOI: 10.4103/jfmpc.jfmpc_45_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 07/18/2023] Open
Affiliation(s)
- Archana Kumari
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naval K. Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Divjyot Kaur
- Department of Home Science, University of Delhi, Delhi, India
| | - Geetha Balsarkar
- Department of Obstetrics and Gynaecology, Seth G. S. Medical College, Mumbai, Maharashtra, India
| | - Anita Malhotra
- Department of Home Science, University of Delhi, Delhi, India
| | - Manju Puri
- Director Professor and Head, Department of Obstetrics and Gynaecology, LHMC and SSK Hospital, New Delhi, India
| | - Achla Batra
- President, Association of Obstetricians and Gynaecologists of Delhi (AOGD), New Delhi, India
- Professor, Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Jagmeet Madan
- National President, Indian Dietetic Association, New Delhi, India
| | - Shakun Tyagi
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Kiran Guleria
- Department of Obstetrics and Gynaecology, University College of Medical Sciences, New Delhi, India
| | - Anjali Dabral
- Professor and Head, Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Siddharth Sarkar
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Aruna Nigam
- Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences & Research, New Delhi, India
| | - Wareesha Anwar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandhya Kamath
- Former Dean, LT Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
- Former Dean, Seth G. S. Medical College, and KEM Hospital, Mumbai, Maharashtra, India
| | - Neerja Bhatla
- Professor and Head, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - S. Shantha Kumari
- President, The Federation of Obstetric and Gynaecological Societies of India, India
| | - Raman Kumar
- President, Academy of Family Physicians of India, India
- President, World Organization of Family Doctors (WONCA), New Delhi, India
| | | | - Srikumar Venkataraman
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi, India
| | - Tanveer Kaur
- Department of Psychology, University of Delhi, Delhi, India
| | - Asmita Muthal Rathore
- Director Professor and Head, Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Gauri Shankar Kaloiya
- Department of Clinical Psychology and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Anupam Prakash
- Department of Medicine, LHMC and SSK Hospital, New Delhi, India
| | | | - Archana Verma
- Vice President, The Federation of Obstetric and Gynaecological Societies of India, India
| | - Rakhi Singh
- The Federation of Obstetric and Gynaecological Societies of India, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Upendra Baitha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kamlesh Tewary
- President, Association of the Physicians of India, India
| | - Anoop Misra
- Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, New Delhi, India
- Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India
- President, Diabetes Foundation (India) (DFI), New Delhi, India
| | - Randeep Guleria
- Director, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
6
|
Saxon CE, Seely EW, Bertin KB, Suresh K, Skurnik G, Roche AT, Schultz C, Blair RA, Nicklas JM. Self-Efficacy and Readiness to Change Among Women with Recent Gestational Diabetes Engaging in a Web-Based Lifestyle Intervention: The Balance After Baby Intervention Trial. Am J Lifestyle Med 2023. [DOI: 10.1177/15598276231155147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Few evidence-based programs exist to help women with a history of gestational diabetes reduce their risk of developing type 2 diabetes. In secondary analyses from a randomized clinical trial of a web-based lifestyle intervention program for postpartum women with recent gestational diabetes, we studied changes in self-efficacy for diet and physical activity and readiness to change health behaviors. Women were randomized at ∼6 weeks postpartum and completed questionnaires at 6 weeks and 6, 12, 18, and 24 months. Our study included 181 women (mean age 32.4 ± 5.2 years; 48% White, 19% Asian, 14% Black or African American, 17% other/mixed race; 34% Hispanic). In a linear mixed effects model, women in the intervention had significantly greater improvement in overall self-efficacy scores for physical activity compared with the control group at 24 months (difference in change scores between groups .35, 95% CI: .03 to .67, P = .03). The intervention group also demonstrated significantly greater improvement in self-efficacy scores for both physical activity subdomains, specifically “sticking to it” at 24 months and “making time” at 12 months. Participants in the intervention did not experience a significant difference in change in self-efficacy for diet or readiness to change compared with those in the control arm.
Collapse
Affiliation(s)
- Cara E. Saxon
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Ellen W. Seely
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Kaitlyn B. Bertin
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Krithika Suresh
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Geraldine Skurnik
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Andrea T. Roche
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Claire Schultz
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Rachel A. Blair
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| | - Jacinda M. Nicklas
- Department of Medicine, University of Colorado, Aurora, CO, USA (CS); Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (ES, GS, AR); ACCORDS (Adult and Child Center for Outcomes Research and Delivery Science), University of Colorado School of Medicine, Aurora, CO, USA (KB); Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA (KS); Department of Obstetrics
| |
Collapse
|
7
|
Cultural adaptation and validation of the "Pregnancy Physical Activity Questionnaire" for the Portuguese population. PLoS One 2023; 18:e0279124. [PMID: 36626393 PMCID: PMC9831324 DOI: 10.1371/journal.pone.0279124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The lack of instruments to assess the level of physical activity in pregnant women, led to the development of the PPAQ (Pregnancy Physical Activity Questionnaire), a self-administered questionnaire, which has already been translated in several countries and has already been used in several studies. AIM(S) Translate and adapt the PPAQ into Portuguese and test its reliability and validity. METHODS An analytical observational study was carried out. Linguistic and semantic equivalence was performed through translation and back-translation and content validity was tested by a panel of experts. To test reliability, a test-retest was performed on a sample of 184 pregnant women, with an interval of 7 days and the ICC was used. To test the criterion validity, Pearson's correlation coefficient (r) was used between the PPAQ and the accelerometer, in a sample of 226 pregnant women. FINDINGS The questionnaire was considered comprehensive. The ICC values of Reliability were: total score (0.77); sedentary activities (0.87); light-intensity activities (0.76); moderate-intensity activities (0.76); vigorous-intensity activities (0.70). For criterion validity was obtained a coefficient correlation of r = -0.030, considered weak and negative, for total activity. DISCUSSION This study describes the translation and validation process of the PPAQ questionnaire from English to Portuguese. The final version of the PPAQ was considered as a valid instrument in terms of content to measure physical activity and was referred to as being simple to apply and easy to understand. CONCLUSION The PPAQ has content validity, excellent reliability and weak criterion validity, as in the original version.
Collapse
|
8
|
Clinical Practice Guidelines for Weight Management in Postpartum Women: An AIIMS-DST Initiative in Association with FOGSI. J Obstet Gynaecol India 2022; 72:99-103. [PMID: 35492855 PMCID: PMC9008111 DOI: 10.1007/s13224-022-01654-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022] Open
|
9
|
Kumari A, Ranjan P, Vikram NK, Kaur D, Balsalkar G, Malhotra A, Puri M, Batra A, Madan J, Tyagi S, Guleria K, Dabral A, Sarkar S, Nigam A, Anwar W, Kamath S, Bhatla N, Kumari SS, Kumar R, Choranur A, Venkataraman S, Kaur T, Rathore AM, Kaloiya G, Prakash A, Tiwaskar M, Verma A, Singh R, Sharma KA, Baitha U, Tewary K, Misra A, Guleria R. Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative. Diabetes Metab Syndr 2022; 16:102425. [PMID: 35248972 DOI: 10.1016/j.dsx.2022.102425] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings. METHODS The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations. RESULTS The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations. CONCLUSION The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.
Collapse
Affiliation(s)
- Archana Kumari
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Naval K Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Divjyot Kaur
- Department of Home Science, University of Delhi, New Delhi, India
| | - Geetha Balsalkar
- Department of Obstetrics and Gynaecology, Seth G. S. Medical College, Mumbai, India
| | - Anita Malhotra
- Food and Nutrition, Department of Home Science, Vice-principal, Lakshmibai College, University of Delhi, New Delhi, India
| | - Manju Puri
- Department of Obstetrics and Gynaecology, LHMC and SSK Hospital, New Delhi, India
| | - Achla Batra
- President, Association of Obstetricians and Gynaecologists of Delhi (AOGD), Professor, Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, India
| | | | - Shakun Tyagi
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Kiran Guleria
- Department of Obstetrics and Gynaecology, University College of Medical Sciences, New Delhi, India
| | - Anjali Dabral
- Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Siddharth Sarkar
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Aruna Nigam
- Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences & Research, New Delhi, India
| | - Wareesha Anwar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandhya Kamath
- Seth G S Medical College and KEM Hospital, Mumbai, LT Municipal Medical College and General Hospital, Mumbai, India
| | - Neerja Bhatla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - S Shantha Kumari
- The Federation of Obstetric and Gynaecological Societies of India, India
| | - Raman Kumar
- Academy of Family Physicians of India, India
| | - Ambuja Choranur
- President, Indian Menopause Society, Former Professor and Head, Department of Obstetrics and Gynaecology, Osmania Medical College, Hyderabad, India
| | - Srikumar Venkataraman
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi, India
| | - Tanveer Kaur
- Department of Psychology, University of Delhi, New Delhi, India
| | - Asmita Muthal Rathore
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Gaurishankar Kaloiya
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Anupam Prakash
- Department of Medicine, LHMC and SSK Hospital, New Delhi, India
| | | | - Archana Verma
- The Federation of Obstetric and Gynaecological Societies of India, India
| | - Rakhi Singh
- Endocrinology Committee, The Federation of Obstetric and Gynaecological Societies of India, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Upendra Baitha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kamlesh Tewary
- All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Misra
- Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC) and President, Diabetes Foundation (India), New Delhi, India
| | | |
Collapse
|
10
|
Huang S, Magny-Normilus C, McMahon E, Whittemore R. Systematic Review of Lifestyle Interventions for Gestational Diabetes Mellitus in Pregnancy and the Postpartum Period. J Obstet Gynecol Neonatal Nurs 2021; 51:115-125. [PMID: 34843670 DOI: 10.1016/j.jogn.2021.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To examine the characteristics and effectiveness of lifestyle interventions for gestational diabetes mellitus (GDM) in pregnancy and the postpartum period to prevent Type 2 diabetes. DATA SOURCES We conducted searches in seven databases, including Ovid MEDLINE, CINAHL, Ovid Embase, Cochrane Central, Web of Science, Ovid PsycInfo, and ProQuest Dissertations and Theses for articles published from inception to January 2021. STUDY SELECTION We included articles on controlled intervention studies in which researchers evaluated a lifestyle intervention provided during pregnancy and the postpartum period for women with or at risk for GDM that were published in English. DATA EXTRACTION Twelve articles that were reports of seven studies met the inclusion criteria. In some cases, more than one article was selected from the same study. For example, articles reported different outcomes from the same study. We extracted data with the use of a data collection form and compared and synthesized data on study design, purpose, sample, intervention characteristics, recruitment and retention, and outcomes. DATA SYNTHESIS All seven studies focused on weight management and/or healthy lifestyle behaviors (diet and physical activity). Outcomes included glucose regulation, weight, lifestyle behaviors, and knowledge. The interventions varied in duration/dosage, strategies, and modes of delivery. In four studies, researchers reported interventions that had significant effects on improving glucose regulation and/or weight change. Some characteristics from the four effective interventions included goal setting, individualized care, and good retention rates. In the other three studies, limitations included low rates of participant retention, lack of personalized interventions, and limited population diversity or lack of culturally sensitive care. CONCLUSION Lifestyle interventions provided during and after pregnancy to reduce the risk associated with GDM have the potential to improve outcomes. Health care counseling to promote healthy lifestyle behaviors related to the prevention of Type 2 diabetes is needed at different stages of maternity care for women with GDM. Additional high-quality studies are needed to address the limitations of current studies.
Collapse
|
11
|
Hawkins M, Marcus B, Pekow P, Rosal MC, Tucker KL, Spencer RMC, Chasan-Taber L. The Impact of a Randomized Controlled Trial of a Lifestyle Intervention on Sleep Among Latina Postpartum Women. Ann Behav Med 2021; 55:892-903. [PMID: 33580651 DOI: 10.1093/abm/kaaa118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Poor sleep is associated with adverse outcomes among postpartum women. Exercise may improve sleep, but this has not been well examined in the postpartum period. PURPOSE To examine the impact of a culturally modified, individually tailored lifestyle intervention on sleep outcomes among postpartum Latina women. METHODS Estudio PARTO was a randomized controlled trial aimed at reducing Type 2 diabetes among Latina women with abnormal glucose tolerance in pregnancy. Participants were randomized to a lifestyle (i.e., diet and exercise; n = 70) or a health and wellness control intervention (n = 78) in late pregnancy (baseline). The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality (PSQI score), onset latency (minutes per night), duration (hours per night), efficiency (percentage of the time in bed asleep), and daytime dysfunction at baseline, 6 weeks, 6 months, and 12 months postpartum. RESULTS Mean PSQI score (6.56 ± 3.87), sleep duration (6.84 ± 1.75 hr/night), and sleep efficiency (79.70% ± 18.10%) did not differ between the arms at baseline. Mixed-effects models indicated a greater decrease of 1.29 in PSQI score (i.e., improved sleep quality) in the lifestyle versus health and wellness arm (95% confidence interval [CI] = -2.50 to -0.08, p = .04) over follow-up. There was the suggestion of a smaller decrease in sleep duration (mean = 0.48 hr/night, 95% CI = -0.10 to 1.06, p = .10) in the lifestyle versus health and wellness arm. There were no statistically significant differences in other sleep outcomes between arms. CONCLUSIONS Findings suggest that lifestyle interventions improve sleep quality but not sleep duration, sleep onset latency, sleep efficiency, or daytime dysfunction in postpartum Latina women and, therefore, may hold promise for improving subsequent mental and physical health in this population. CLINICAL TRIALS REGISTRATION NCT01679210.
Collapse
Affiliation(s)
- Marquis Hawkins
- Department of Epidemiology, University of Pittsburgh, Public Health, Pittsburgh, PA, USA
| | - Bess Marcus
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Penelope Pekow
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA, USA
| | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine L Tucker
- Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Rebecca M C Spencer
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, MA, USA
| | - Lisa Chasan-Taber
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA, USA
| |
Collapse
|
12
|
Palnati M, Marcus BH, Pekow P, Rosal MC, Manson JE, Chasan-Taber L. The Impact of a Lifestyle Intervention on Postpartum Weight Retention Among At-Risk Hispanic Women. Am J Prev Med 2021; 61:44-54. [PMID: 33994252 PMCID: PMC8217276 DOI: 10.1016/j.amepre.2021.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This study assesses the impact of a culturally modified, motivationally targeted, individually tailored intervention on postpartum weight retention among Hispanic women with abnormal glucose tolerance during pregnancy. METHODS Estudio Parto (Project Aiming to Reduce Type twO diabetes) was an RCT conducted in Western Massachusetts (collected 2013‒2017, analyzed 2018-2020). Hispanic women with blood glucose ≥140 mg/dL (7.77 mmol/L) on routine nonfasting oral glucose challenge test were randomized to a Lifestyle Intervention (n=100) focusing on healthy exercise and diet or to a comparison Health and Wellness Intervention (n=104) with no mention of exercise or diet behavior changes. The primary outcome was change in weight, calculated as the difference between prepregnancy weight and 6-week, 6-month, and 12-month postpartum weight. The secondary outcome was achievement of weight reduction to prepregnancy weight if prepregnancy BMI was normal, or a 5% reduction if prepregnancy BMI was overweight/obese. RESULTS In intent-to-treat analyses, there were no significant differences in weight change pattern between the intervention arms across all follow-up timepoints (β=0.03, 95% CI= -3.38, 3.45). However, at 12 months postpartum, women in the Lifestyle Intervention arm had a statistically significant 2.5-fold higher odds of meeting the secondary weight reduction outcome (OR=2.52, 95% CI=1.09, 5.82) than women in the Health and Wellness arm. Regardless of intervention arm, women who reported higher levels of postpartum sports/exercise had a greater decrease in weight (β= -2.39, 95% CI= -4.66, -0.13, p=0.04) than women reporting lower levels. CONCLUSIONS In this randomized trial among Hispanic women, no significant overall differences in weight change pattern between intervention arms were observed. Higher levels of self-reported physical activity were associated with greater weight loss in both arms.
Collapse
Affiliation(s)
- Madhuri Palnati
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Bess H Marcus
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Penelope Pekow
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Chasan-Taber
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts.
| |
Collapse
|
13
|
Phelan S, Jelalian E, Coustan D, Caughey AB, Castorino K, Hagobian T, Muñoz-Christian K, Schaffner A, Shields L, Heaney C, McHugh A, Wing RR. Protocol for a randomized controlled trial of pre-pregnancy lifestyle intervention to reduce recurrence of gestational diabetes: Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional. Trials 2021; 22:256. [PMID: 33827659 PMCID: PMC8024941 DOI: 10.1186/s13063-021-05204-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with several maternal complications in pregnancy, including preeclampsia, preterm labor, need for induction of labor, and cesarean delivery as well as increased long-term risks of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM raises the risk for complications in offspring as well, including stillbirth, macrosomia, and birth trauma, and long-term risk of metabolic disease. One of the strongest risk factors for GDM is the occurrence of GDM in a prior pregnancy. Preliminary data from epidemiologic and bariatric surgery studies suggest that reducing body weight before pregnancy can prevent the development of GDM, but no adequately powered trial has tested the effects of a maternal lifestyle intervention before pregnancy to reduce body weight and prevent GDM recurrence. METHODS The principal aim of the Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional is to determine whether a lifestyle intervention to reduce body weight before pregnancy can reduce GDM recurrence. This two-site trial targets recruitment of 252 women with overweight and obesity who have previous histories of GDM and who plan to have another pregnancy in the next 1-3 years. Women are randomized within site to a comprehensive pre-pregnancy lifestyle intervention to promote weight loss with ongoing treatment until conception or an educational control group. Participants are assessed preconceptionally (at study entry, after 4 months, and at brief quarterly visits until conception), during pregnancy (at 26 weeks' gestation), and at 6 weeks postpartum. The primary outcome is GDM recurrence, and secondary outcomes include fasting glucose, biomarkers of cardiometabolic disease, prenatal and perinatal complications, and changes over time in weight, diet, physical activity, and psychosocial measures. DISCUSSION The Gestational Diabetes Prevention /Prevención de la Diabetes Gestacional is the first randomized controlled trial to evaluate the effects of a lifestyle intervention delivered before pregnancy to prevent GDM recurrence. If found effective, the proposed lifestyle intervention could lay the groundwork for shifting current treatment practices towards the interconception period and provide evidence-based preconception counseling to optimize reproductive outcomes and prevent GDM and associated health risks. TRIAL REGISTRATION ClinicalTrials.gov NCT02763150 . Registered on May 5, 2016.
Collapse
Affiliation(s)
- Suzanne Phelan
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Elissa Jelalian
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI USA
| | - Donald Coustan
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI USA
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | | | - Todd Hagobian
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Karen Muñoz-Christian
- Department of World Languages and Cultures, California Polytechnic State University, San Luis Obispo, CA USA
| | - Andrew Schaffner
- Statistics Department, California Polytechnic State University, San Luis Obispo, CA USA
| | - Laurence Shields
- Dignity Health, Marian Regional Medical Center, Santa Maria, CA USA
| | - Casey Heaney
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Angelica McHugh
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, USA
| | - Rena R. Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, USA
| |
Collapse
|