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Trial Design Excessive gestational weight gain (GWG) can increase pregnancy morbidity and is particularly problematic for women with pregestational obesity. A lifestyle modification intervention was introduced to gravida with obesity to decrease excessive GWG as compared to usual care (UC). Methods A randomized controlled trial was conducted to improve healthy lifestyle behaviors to manage appropriate GWG. Consenting participants with prepregnancy obesity and singletons ≤17 weeks were randomized to (1) Usual Care (UC): usual written educational materials and counseling by obstetric provider or (2) Enhanced Care (EC): UC plus (a) personalized letter from physician detailing appropriate GWG; (b) access to individualized GWG chart; (c) ongoing counseling with registered dietitian/nutritionist (RDN). The primary outcome was proportion with GWG ≤9.1 kg, as this is upper limit recommended by Institute of Medicine (IOM). Total GWG and GWG as less than/within/greater than IOM recommendations (in aggregate and stratified by obesity class), and pregnancy/neonatal outcomes were evaluated as secondary outcomes. Results Analyses included 105 participants in EC and 109 in UC arms. The groups had similar demographics: 46% with class I obesity, 26% class II, and 28% class III. There were no group differences for any GWG, pregnancy, or neonatal outcomes when analyzed in aggregate. As compared to those randomized to the EC arm, participants in UC arm with class I obesity gained 1.4 kg less and those with class II obesity were significantly more likely to gain within IOM guidelines (14.8% vs. 40.0%, adjusted p = 0.04). Participants with class III obesity randomized to EC arm were more likely to gain within IOM guidelines as compared to participants randomized to UC arm (29.0% vs. 6.7%, adjusted p = 0.02). Conclusion There were no differences in GWG observed between groups when analyzing participants in aggregate. However, a physician's letter detailing appropriate GWG, patient portal access to a personalized GWG chart, and RDN consultation were helpful for encouraging GWG within IOM guidelines for women with prepregnancy class III obesity. Women with class I or II obesity had better GWG outcomes without these additional interventions.

Background The advent of patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Improved understanding of how patients think about and define their health is needed to more effectively “activate” patients, and to nurture and support patients’ efforts to improve their health. Researchers have intimated for over 25 years that rural populations approach health in a distinct fashion that may differ from their non-rural counterparts. Methods We conducted a systematic review of the literature to assess the extent and strength of evidence for rural definition of health. Studies were eligible for inclusion if they were published in English, reported on original research and presented findings or commentary relevant to rural definition of health, were published over the last 40 years, and were based on observations of rural U.S., Canadian, or Australian populations. Two reviewers were assigned to each selected article and blinded to the other reviewer’s comments. For discordant reviews, a third blinded review was performed. Results Of the 125 published articles identified from the literature, 34 included commentary or findings relevant to a rural definition of health. Of these studies, 6 included an urban comparison group. Few studies compared rural and urban definitions of health directly. Findings relevant to rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence. This review largely confirmed many general characteristics on rural views of health, but also documented the extensive methodological limitations, both in terms of quantity and quality, of studies that empirically compare rural vs. urban samples. Most notably, the evidence base in this area is weakened by the frequent absence of parallel comparison groups and standardized assessment tools. Conclusions To engage and activate rural patients in their own healthcare, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed hold distinct views on how to define health, but more rigorous studies are needed to confirm these findings.

Determine the impact of long-term non-surgical weight loss maintenance on clinical relevance for osteoarthritis, cancer, opioid use, and depression/anxiety and healthcare resource utilization. A cohort of adults receiving primary care within Geisinger Health System between 2001-2017 was retrospectively studied. Patients with ≥3 weight measurements in the two-year index period and obesity at baseline (BMI ≥30 kg/m2) were categorized: Obesity Maintainers (reference group) maintained weight within +/-3%; Weight Loss Rebounders lost ≥5% body weight in year one, regaining ≥20% of weight loss in year two; Weight Loss Maintainers lost ≥5% body weight in year one, maintaining ≥80% of weight loss. Association with development of osteoarthritis, cancer, opioid use, and depression/anxiety, was assessed; healthcare resource utilization was quantified. Magnitude of weight loss among maintainers was evaluated for impact on health outcomes. In total, 63,567 patients were analyzed including 67% Obesity Maintainers, 19% Weight Loss Rebounders, and 14% Weight Loss Maintainers; median follow-up was 9.7 years. Time until osteoarthritis onset was delayed for Weight Loss Maintainers compared to Obesity Maintainers (Logrank test p <0.0001). Female Weight Loss Maintainers had a 19% and 24% lower risk of developing any cancer (p = 0.0022) or obesity-related cancer (p = 0.0021), respectively. No significant trends were observed for opioid use. Weight loss Rebounders and Maintainers had increased risk (14% and 25%) of future treatment for anxiety/depression (both <0.0001). Weight loss maintenance of >15% weight loss was associated with the greatest decrease in incident osteoarthritis. Healthcare resource utilization was significantly higher for Weight Loss Rebounders and Maintainers compared to Obesity Maintainers. Increased weight loss among Weight Loss Maintainers trended with lower overall healthcare resource utilization, except for hospitalizations. In people with obesity, sustained weight loss was associated with greater clinical benefits than regained short-term weight loss and obesity maintenance. Higher weight loss magnitudes were associated with delayed onset of osteoarthritis and led to decreased healthcare utilization.

Background Low-income, rural pregnant women are at disproportionate risk for adverse pregnancy outcomes as well as future cardiovascular risk. Currently, less than half of eligible women enroll in the Women, Infants, and Children’s (WIC) Program. This study aims to evaluate whether integrating clinical care and social care may advance health equity and reduce health disparities by directly linking women receiving obstetric care to the Special Supplemental Nutrition Program for WIC and/or a Registered Dietitian/Nutritionist (RDN). Methods This pragmatic study is situated in real-world care and utilizes a randomized controlled trial design. A total of 240 low-income, rural, pregnant patients will be recruited from Geisinger (Pennsylvania, USA) obstetric clinics and randomized to receive one of four models: (1) Clinic; (2) Clinic-WIC; (3) Clinic-RDN, or (4) Clinic-WIC-RDN. Participants provide consent for electronic referrals that directly link their contact information from the electronic health record to WIC and/or RDN. Patients in the Clinic model receive standard prenatal care, which includes provision of basic information about WIC. The Clinic-WIC model includes a clinical decision alert to queue clinical staff to ask about WIC interest and place a referral to WIC using a social health access referral platform. In turn, WIC staff contact the pregnant woman about enrollment. The Clinic-RDN model includes a referral to an RDN for telehealth counseling to promote heart healthy eating and food resource management. The Clinic-WIC-RDN model includes referrals to both WIC and RDN. The primary outcome is difference in WIC enrollment between the Clinic and Clinic-RDN models versus the Clinic-WIC and Clinic-WIC-RDN arms at 6-months post-baseline. Secondary endpoints include WIC retention and adherence, change in participant behavior, skills, and food security, preterm delivery, birthweight, and maternal and child health outcomes. Implementation outcome measures include acceptability, appropriateness, and feasibility from the perspective of clinic and WIC staff. Discussion Study findings will inform system models that integrate clinic care and social care to improve health equity among a high-risk population. Specifically, these findings will advance implementation of strategies to increase enrollment in a widely available but underutilized food provision program during pregnancy. Trial registration ClinicalTrials.gov identifier (NCT06311799). Registered 3/13/2024.

Background The influence of home obesogenic environments, as assessed by the validated Family Nutrition and Physical Activity (FNPA) tool, and child obesity during the COVID pandemic were evaluated using electronic health records in this retrospective cohort study. Methods Historical data on BMI and the FNPA screening tool were obtained from annual well-child visits within the Geisinger Health System. The study examined youth ages 2–17 that had a BMI record and an FNPA assessment prior to the pandemic (BMI 3/1/19–2/29/20), 1 BMI record 3 months into the pandemic (6/1/20–12/31/20) and 1 BMI in the second year of the pandemic (1/1/21–12/31/21). Tertiles of obesity risk by FNPA score were examined. Mixed-effects linear regression was used to examine change in BMI slope (kg/m 2 per month) pre-pandemic to pandemic using FNPA summary and subscales scores as predictors and adjusting for confounding factors. Results The analyses included 6,746 children (males: 51.7%, non-Hispanic white: 86.6%, overweight:14.8%, obesity:10.3%, severe obesity: 3.9%; mean(SD) age: 5.7(2.8) years). The rate of BMI change in BMI was greatest from early pandemic compared to pre-pandemic for children in lowest versus highest tertiles of FNPA summary score (0.079 vs. 0.044 kg/m 2 ), FNPA-Eating (0.068 vs. 0.049 kg/m 2 ), and FNPA-Activity (0.078 vs. 0.052 kg/m 2 ). FNPA summary score was significantly associated with change in BMI from the pre-pandemic to early pandemic period ( p  = 0.014), but not associated with change in BMI during the later pandemic period. Conclusions This study provides additional insight into the changes in the rate of BMI change observed among children and adolescents in the United States during the COVID-19 pandemic. The FNPA provides ample opportunity to continue our exploration of the negative impact of the COVID-19 pandemic on the longitudinal growth patterns among children and adolescents.

We explored how depressive symptoms, perceived stress, and food security of people with metabolic syndrome (MetS) changed during the COVID-19 pandemic. An online survey was administered from October 2019 through March 2020, to participants in a 2-year lifestyle intervention trial to reverse MetS; the survey was repeated during the COVID-19 pandemic. Outcomes were a change in depressive symptoms, perceived stress, and food security as measured by the Patient Health Questionnaire-8 (PHQ-8), Perceived Stress Scale, and US Department of Agriculture's 10-item Adult Food Security Module. We analyzed changes in outcomes with measures of association, paired t tests, repeated measures, and independent t tests. Survey respondents (N = 132) were mostly female (67%), White (70%), and middle-aged, with a median income of $86,000. Frequency of depressive symptoms increased from baseline to follow-up and the increase was related to lower mean (SD) baseline vitality (44.4 [20.7] vs 60.3 [18.9]; P = .01) and mental health decline (71.0 [14.3] vs 82.0 [10.4]; P = .002). Mean (SD) perceived stress was significantly higher at baseline than follow-up (18.5 [6.4] vs 14.9 [7.2]; P < .001). Food security increased from 83% at baseline to 90% at follow-up (P < .001). Movement to or continued food insecurity (n = 13) tended to be associated with a racial or ethnic minority group (P = .05). A sample at high risk for COVID-19 did not experience increased stress or food insecurity, but demonstrated increased depressive symptoms after the onset of the COVID-19 pandemic, with some baseline susceptibility.

Background Obesity disproportionally impacts rural, lower-income children in the United States. Primary care providers are well-positioned to engage parents in early obesity prevention, yet there is a lack of evidence regarding the most effective care delivery models. The ENCIRCLE study, a pragmatic cluster-randomized controlled trial, will respond to this gap by testing the comparative effectiveness of standard care well-child visits (WCV) versus two enhancements: adding a patient-reported outcome (PRO) measure (PRO WCV) and PRO WCV plus Food Care (telehealth coaching and a grocery store tour). Methods A total of 2,025 parents and their preschool-aged children (20–60 months of age) will be recruited from 24 Geisinger primary care clinics, where providers are randomized to the standard WCV, PRO WCV, or PRO WCV plus Food Care intervention arms. The PRO WCV includes the standard WCV plus collection of the PRO—the Family Nutrition and Physical Activity (FNPA) risk assessment—from parents. Parents complete the PRO in the patient-portal or in the clinic (own device, tablet, or kiosk), receive real-time feedback, and select priority topics to discuss with the provider. These results are integrated into the child’s electronic health record to inform personalized preventive counseling by providers. PRO WCV plus Food Care includes referrals to community health professionals who deliver evidence-based obesity prevention and food resource management interventions via telehealth following the WCV. The primary study outcome is change in child body mass index z-score (BMIz), based on the World Health Organization growth standards, 12 months post-baseline WCV. Additional outcomes include percent of children with overweight and obesity, raw BMI, BMI50, BMIz extended, parent involvement in counseling, health behaviors, food resource management, and implementation process measures. Discussion Study findings will inform health care systems’ choices about effective care delivery models to prevent childhood obesity among a high-risk population. Additionally, dissemination will be informed by an evaluation of mediating, moderating, and implementation factors. Trial registration ClinicalTrials.gov identifier (NCT04406441); Registered May 28, 2020.

Purpose Few states or local school districts mandate a minimum time for lunch. With increasing pressure on schools to maximize instructional time, many US students have witnessed continued reductions in the time allotted to lunch periods and, thus, less time to choose from an increasing number of food options. This study aims to investigate middle and high school students’ preferences regarding the time available for school lunches and whether the amount of time would affect their food choice preferences. Design/methodology/approach This study investigated students’ self-reported lunchtime constraints and food choice preferences through a paper-and-pencil survey. The categorical and ratio responses were analyzed using ordinal logistic regression. Findings Students responded that they rarely had enough time to eat school lunch and that the lunch line waiting time strongly or very strongly influenced their food choices. For the students for whom time available for lunch and time in the lunch line influenced what they ate, they were more likely to prefer limited food choices in several categories of the school lunch menu. Practical implications Foodservice professionals who wish to actively promote better nutrition might consider practical ways to reduce the foodservice wait time for students. While making healthier default options (e.g. a fruit or fresh vegetable side) could increase service convenience, time required for students to make informed meal choices should not be compromised. Originality/value Because lunch line waiting time is related to students’ food choices, schools need to review the number and types of food choices offered in terms of whether they encourage students to make more healthful choices. This study offers a unique perspective on the relationship between time and individual food choices in the school lunch environment and how this relationship affects the quality of children’s diets and their eating behaviors.

The prevalence of metabolic syndrome (MetS) continues to increase. The severity of MetS can be defined by the number of components or, more recently, a continuous MetS severity score (MetSSS). However, studies that examine lifestyle factors predictive of MetS severity, in general, are lacking. This study aims to compare lifestyle behaviors (eg, physical activity and diet), health perceptions (eg, overall and mental health perceptions), and psychosocial outcomes (eg, perceived stress and social support) among people with a varied number of MetS components and to evaluate associations with MetSSS. This cross-sectional study utilized baseline data from a randomized controlled trial of 618 participants with MetS recruited from 5 different sites across the US We collected data using accelerometers, standard questionnaires, bloodwork, and doing physical measurements. We used a series of separate linear regression models (unadjusted and adjusted) to evaluate differences in lifestyle behaviors, health perceptions, and psychosocial factors between people with 3, 4, and 5 MetS components. We conducted additional linear regression models (unadjusted and adjusted) to assess the association between these same variables and a continuous MetSSS. Lifestyle behaviors, health perceptions, and psychosocial factors were not different among people with 3, 4, and 5 MetS components. However, in the adjusted models, a lower MetSSS was associated with more average daily steps (β = -631.69, < 0.001), healthier overall health perception (β = -0.14, = 0.014), more social support for physical activity from friends (β = -0.89, = 0.011) and more social support for healthy eating from friends (β = -0.42, = 0.015). The MetSSS was shown to be more sensitive to modifiable lifestyle factors compared to the number of MetS components, indicating the importance of using the MetSSS in lifestyle interventions targeting MetS to achieve MetS remission.

IntroductionWeight loss, consumption of a Dietary Approaches to Stop Hypertension dietary pattern, reduced sodium intake and increased physical activity have been shown to lower blood pressure (BP). Use of web-based tools and telehealth to deliver lifestyle counselling could be potentially scalable solutions to improve BP through behavioural modification though limited data exists to support these approaches in clinical practice.Methods and analysisThis randomised controlled trial will compare the efficacy of a telehealth versus self-directed lifestyle intervention in lowering 24-hour SBP in patients with overweight/obesity (body mass index ≥25 kg/m2) and 24-hour SBP 120–160 mm Hg. All participants receive personalised recommendations to improve dietary quality based on a web-based Food Frequency Questionnaire, access to an online comprehensive weight management programme and a smartphone dietary app. The telehealth arm additionally includes weekly calls with registered dietitian nutritionists who use motivational interviewing. The primary outcome is change from baseline to 12 weeks in 24-hour SBP. Secondary outcomes include changes from baseline in 24-hour diastolic BP, daytime SBP, nighttime SP, daytime diastolic BP, nighttime diastolic BP, total Healthy Eating Index-2015 score, weight, waist circumference and physical activity. Other prespecified outcomes will include change in individual components of the Healthy Eating Index-2015 score, and satisfaction with the Healthy BP research study measured on a 5-point Likert scale.Ethics and disseminationThe study has been approved by the Geisinger Institutional Review Board. Results will be disseminated through peer-reviewed publications and conference presentations.Trial registration numberNCT03700710.