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Lifestyle interventions regularly rely on study staff to implement the intervention and collect outcomes data directly from study participants. This study describes the experiences of project staff in two randomized controlled trials of a postpartum lifestyle intervention to reduce risk factors for type 2 diabetes in Latinas. Latinas are the fastest growing minority group in the U.S. and have the highest rates of type 2 diabetes after a diagnosis of gestational diabetes mellitus. The challenges of implementing lifestyle interventions for postpartum women have been poorly documented. A qualitative focus group was conducted with eight staff members (five health educators and three health interviewers) involved in Proyecto Mama and Estudio Parto. The discussion was audio recorded, transcribed, and coded in NVivo. Focus group topics included: 1) participant recruitment, 2) participant retention, 3) implementation of the lifestyle intervention, 4) assessment of behavior change, 5) overall challenges and rewarding aspects of the trial, and 6) recommended changes for future trials. Key themes emerged regarding enabling factors and barriers to implementing a lifestyle intervention in postpartum Latinas. Enabling factors included: a) the staff’s belief in the importance of the intervention, b) opportunities associated with the longitudinal nature of the trial, c) belief that the staff could empower participants to make behavior change, d) benefits of flexible intervention sessions, and e) connection with participants due to shared cultural backgrounds. Barriers included: a) participant stressors: home, food, and financial insecurity, b) low health literacy, c) issues related to recent immigration to the continental U.S., d) handling participant resistance to behavior change, e) involvement of family members in assessment visits, f) limitations of the assessment tools, and g) time limitations. Findings highlight the challenging contexts that many study participants face, and shed light on the potentially influential role of health educators and interviewers in intervention implementation and data collection. Specific recommendations are made for strategies to improve adherence to diabetes prevention programs in postpartum underserved and minority populations in this challenging, transitional period of life. NCT01679210 . Registered 5 September 2012; NCT01868230 . Registered 4 June 2013.

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 (n=104) Intervention 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) as compared with 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) compared with 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. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01679210.

Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006–2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4–6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02–1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02–1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.

Aims. The purpose of the study was to assess the effect of leisure and occupational physical activity on the risk of diagnosed and undiagnosed prediabetes among females and males. Methods. A sample of 17,871 non-pregnant adults was drawn from the 2007-2014 National Health and Nutrition Examination Survey. Multinomial logistic regression tested associations between moderate-to-vigorous physical activity (MVPA) and risk of diagnosed prediabetes and undiagnosed prediabetes, compared to no prediabetes. Results. Females and males who met guidelines for total MVPA (i.e., ≥10 MET-hrs/week) had a statistically significant lower risk of undiagnosed prediabetes (OR range: 0.50-0.65) as compared to those with no MVPA, however findings were no longer statistically significant after adjustment for diabetes risk factors. In terms of diagnosed prediabetes, females meeting guidelines had lower risk (OR range: 0.65-0.76), while only males engaging in the most MVPA had lower risk; findings were no longer significant after adjustment. Patterns were similar for leisure-time MVPA, but conflicting for occupational PA; females with 10-20 MET-hrs/week had a higher risk of diagnosed prediabetes (OR =1.71, 95% CI 1.11-2.61) and males with >20 MET-hrs/week had a higher risk for undiagnosed prediabetes (OR =1.17, 95% CI 1.02-1.35) after adjustment. Conclusions. This study adds to the sparse body of literature on physical activity and prediabetes, particularly with its inclusion of occupational MVPA.

Engaging in recommended levels of physical activity during pregnancy can provide a host of physical and mental health benefits for the expecting mother and her child. However, methodological issues related to physical activity measurement have plagued many studies examining the effects of physical activity during this important life stage. Burgeoning support exists for the more widespread use of objective methods, and accelerometers specifically, for an accurate appraisal of maternal physical activity. In this commentary, we highlight discrepancies between activity estimates obtained via self-report and objective measures and describe the implications of erroneous measurement when making clinical recommendations and in conducting future physical activity and pregnancy research. Most importantly, we aim to foster academic discussion and propose a call to action requiring a paradigm shift where we acknowledge the shortcomings of self-report and move toward an empirically driven approach for physical activity measurement. Results from more high-quality research studies will help support public health messaging and facilitate trust among health care providers, clinical researchers, and expecting mothers regarding the health benefits of physical activity recommendations.

Background: Preterm birth and low birthweight contribute substantially to the disproportionately high infant mortality rates experienced by Puerto Ricans in the United States. The purpose of this study was to examine whether the timing and pattern of prenatal psychosocial stress increased risk of adverse birth outcomes in this high-risk population. Materials and Methods: Proyecto Buena Salud was a prospective cohort study conducted from 2006 to 2011 among predominantly Puerto Rican women. Participants (n = 1,267) were interviewed in early, mid-, and late pregnancy. We evaluated associations between early and mid-pregnancy stress (Perceived Stress Scale) and preterm birth and low birthweight, and stress at each pregnancy time point and small for gestational age (SGA). Results: Elevated levels of perceived stress in mid-pregnancy increased risk for preterm birth and low birthweight in adjusted analyses, with a linear trend observed for each increasing quartile of stress (p(trend) = 0.01). Women in the highest quartile of stress experienced three times the risk for preterm birth (odds ratio [OR] = 3.50, confidence interval [95% CI]: 1.38–8.87) and low birthweight (OR = 3.53, 95% CI = 1.27–9.86) compared with women in the lowest quartile. Early pregnancy stress was not associated with preterm birth or low birthweight. Increase in stress from early to late pregnancy increased risk for SGA (OR = 1.90, 95% CI = 1.01–3.59); no associations were found between stress at any timepoint and SGA. Conclusion: Elevated levels of mid-pregnancy perceived stress increased risk for preterm birth and low birthweight, and an increase in stress over the course of pregnancy increased risk for SGA in a population of predominantly Puerto Rican women.

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

Vitamin D deficiency is common during pregnancy and higher in Hispanic as compared with non-Hispanic white women. However, the association between vitamin D deficiency and adverse pregnancy outcomes remains unclear and may vary across ethnic groups, in part because of genetic variation in the metabolism of vitamin D. Few studies have included Hispanic women. Therefore, we investigated this association among 237 participants in the Behaviors Affecting Baby and You Study, a randomised trial of an exercise intervention among ethnically diverse prenatal care patients in Massachusetts. Baseline serum 25-hydroxyvitamin D (25(OH)D) was measured at 15·2 (sd 4·7) weeks’ gestation. Information on adverse pregnancy outcomes was abstracted from medical records. Mean 25(OH)D was 30·4 (sd 12·0) ng/ml; 53·2 % of participants had insufficient (se 69·16) g (P=0·045) and 175·52 (se 89·45) g (P=0·051) lower compared with women with sufficient vitamin D levels (≥30 ng/ml). Each 1 ng/ml increase in 25(OH)D was associated with an increased risk for gestational diabetes mellitus among Hispanic women only (relative risk 1·07; 95 % CI 1·03, 1·11) in multivariable analysis. We did not observe statistically significant associations between maternal vitamin D status and other pregnancy outcomes. Our findings provide further support for an adverse impact of vitamin D deficiency on birth weight in Hispanic women.

Maternal depression increases risk of adverse perinatal outcomes, and recent evidence suggests that body image may play an important role in depression. This systematic review identifies studies of body image and perinatal depression with the goal of elucidating the complex role that body image plays in prenatal and postpartum depression, improving measurement, and informing next steps in research. We conducted a literature search of the PubMed database (1996– 2014) for English language studies of (1) depression, (2) body image, and (3) pregnancy or postpartum. In total, 19 studies matched these criteria. Cross-sectional studies consistently found a positive association between body image dissatisfaction and perinatal depression. Prospective cohort studies found that body image dissatisfaction predicted incident prenatal and postpartum depression; findings were consistent across different aspects of body image and various pregnancy and postpartum time periods. Prospective studies that examined the reverse association found that depression influenced the onset of some aspects of body image dissatisfaction during pregnancy, but few evaluated the postpartum onset of body image dissatisfaction. The majority of studies found that body image dissatisfaction is consistently but weakly associated with the onset of prenatal and postpartum depression. Findings were less consistent for the association between perinatal depression and subsequent body image dissatisfaction. While published studies provide a foundation for understanding these issues, methodologically rigorous studies that capture the perinatal variation in depression and body image via instruments validated in pregnant women, consistently adjust for important confounders, and include ethnically diverse populations will further elucidate this association.

Few studies have analyzed the cohort effects of lifecourse socioeconomic position (SEP) on racial disparities in body mass index (BMI) trajectories. We assessed the contribution of lifecourse SEP on racial differences in BMI trajectories among two different age cohorts of women.Four waves of the Americans' Changing Lives' study (1986-2002) were used to compute BMI trajectories for 2194 Black and White women. Multivariable associations of lifecourse SEP variables (father's education, perceived childhood family status, education, income, wealth and financial security) with Wave 1(W1) BMI and BMI change were assessed using mixed models.Black women had higher W1 BMI than White women in both cohorts (women40 years in 1986 (+2.6 kg/mIn this large population-based dataset, results suggest that the contribution of lifecourse SEP to racial disparities in BMI may be established early in adulthood.

Prior studies of the association between physical activity and hypertensive disorders of pregnancy have been conflicting; the majority focused on leisure-time activity only, did not use physical activity questionnaires validated for pregnancy, and were conducted in primarily non-Hispanic white populations.We prospectively evaluated this association among 1240 Hispanic women in Proyecto Buena Salud. The Pregnancy Physical Activity Questionnaire, validated for use in pregnancy, was used to assess pre- and early pregnancy sports/exercise, household/caregiving, occupational and transportation activity. Diagnoses of hypertensive disorders of pregnancy were based on medical record abstraction and confirmed by the study obstetrician.A total of 49 women (4.0%) were diagnosed with a hypertensive disorder of pregnancy, including 32 women (2.6%) with pre-eclampsia. In age-adjusted analyses, high levels of early pregnancy household/caregiving activity were associated with reduced risk of total hypertensive disorders (OR = 0.4, 95% CI 0.1-0.9) and pre-eclampsia (OR = 0.3, 95% CI 0.1-0.9) relative to low levels; however, these findings were no longer statistically significant in multivariable models. Pre-pregnancy activity and pattern of activity from pre- to early-pregnancy were not significantly associated with risk. Finally, sedentary behavior was not significantly associated with hypertensive disorders.Findings from this prospective study of Hispanic women were consistent with those of prior prospective cohorts indicating that physical activity prior to and during early pregnancy does not significantly reduce risk of hypertensive disorders of pregnancy.

We reviewed studies of maternal depression and preterm birth (PTB), low birthweight (LBW) and small-for-gestational-age (SGA) in the context of methodological differences between studies and potential limitations.We conducted a literature search of PubMed (1996-2011) for English-language studies of maternal depression and (1) PTB and gestational age (GA), (2) LBW and birthweight (BW) and (3) SGA. Thirty-six studies met eligibility criteria.Elevated depression levels, particularly in early- to mid-pregnancy, appear to increase risk of PTB and SGA. Findings suggest an increased risk for LBW, but were less consistent. Methodological differences and limitations likely contributed to conflicting findings. A wide range of depression measures were used with the majority of studies utilizing measures not designed, or validated, for pregnant women. Studies failed to assess depression at multiple pregnancy time points, thus constraining the ability to assess the impact of duration and pattern of exposure to depression. Antidepressant use and co-morbid psychosocial factors were rarely considered as potential confounders or effect modifiers.Studies suggest that depression during pregnancy may be an important risk factor for PTB and SGA, and possibly LBW. Improved study methodology is needed to elucidate the consequence of maternal depression on adverse birth outcomes.

Women diagnosed with gestational diabetes mellitus (GDM) are at high risk for future diabetes, with rates of GDM consistently higher in Hispanic than non-Hispanic white women. Currently recognized risk factors for GDM are absent in up to half of affected women, and studies addressing modifiable risk factors for GDM in Hispanic women are sparse.Proyecto Buena Salud is an ongoing prospective cohort study of Hispanic women in Massachusetts designed to assess physical activity, psychosocial stress, and GDM risk. Bilingual interviewers recruit prenatal care patients early in pregnancy and assess activity, trait anxiety, perceived stress, and depressive symptoms using validated questionnaires.Baseline characteristics of the first 632 participants are presented. Women were predominantly young (69%24 years), were unmarried (87%), and had low levels of education (48% had less than high school). Women with high acculturation were less likely to live with a partner (OR: 0.6, 95% CI 0.4-0.8) than women with low acculturation. Few participants met physical activity guidelines during pregnancy (5.2%). Levels of perceived stress (mean 26.9 +/- 7.1), trait anxiety (mean 41.6 +/- 10.4), and depressive symptoms (33.2%) were high.Proyecto Buena Salud represents a high-risk population of pregnant Hispanic women who are predominantly inactive, with higher levels of perceived stress, trait anxiety, and depressive symptoms compared to predominantly non-Hispanic white cohorts studied earlier. Therefore, Proyecto Buena Salud provides a unique opportunity to prospectively evaluate modifiable risk factors for GDM. Findings will inform prenatal behavioral intervention programs designed to address modifiable GDM risk factors.

To examine the association of gestational weight gain and dietary factors with abnormal glucose tolerance (AGT).We conducted a prospective cohort study among 813 Hispanic prenatal care patients in Massachusetts. Gestational weight gain and oral glucose tolerance test results were abstracted from medical records. Dietary intake was assessed using a semi-quantitative food frequency questionnaire. Target weight gain was based on BMI-specific weekly weight gain rates established by the Institute of Medicine (IOM).We observed a statistically significant interaction between prepregnancy BMI and weight gain in relation to AGT (P0.01). Class II/III (BMIor = 35 kg/m2) obese women who had a high rate of weight gain (0.30 kg/week) or who exceeded target weight were 3-4 times as likely to develop AGT compared to women who gained within IOM ranges (OR = 4.2, 95% CI 1.1-16.0, OR = 3.2 95% CI 1.0-10.5, respectively). Decreasing levels of saturated fatty acids and energy-dense snack foods and increasing levels of fiber and polyunsaturated:saturated fat ratio were significantly associated with decreased risk of AGT, independent of gestational weight gain [corrected].Weight gain among class II/III obese women and certain dietary components may represent modifiable risk factors for AGT.

Objectives. We explored whether higher levels of acculturation were associated with higher rates of cigarette smoking among pregnant Hispanic women residing in the United States. Methods. We evaluated data from the Latina Gestational Diabetes Mellitus Study, a prospective study of 1231 Hispanic prenatal care patients conducted from 2000 to 2004 in Massachusetts. Self-reported data on acculturation, cigarette smoking, and covariates were collected by bilingual interviewers using a questionnaire. We conducted logistic regression multivariate analyses to examine the impact of acculturation level on the odds of smoking. Results. Overall, 21% of women reported smoking during pregnancy. Acculturation was associated with elevated smoking rates in pregnant Hispanic women. US-born Hispanic women who preferred English had more than twice the odds of smoking compared with Puerto Rican or foreign-born Hispanic women who preferred Spanish (odds ratio [OR]=2.76, 95% confidence interval [CI] 1.36, 5.63). Conclusions. Our findings suggest that higher-acculturated Hispanic women living in the United States are more likely to smoke cigarettes during pregnancy than are less-acculturated Hispanic women. These results will inform interventions aimed at reducing cigarette smoking during pregnancy among US Hispanic women.

Background Disturbances in glucose metabolism during pregnancy are associated with negative sequalae for both mother and infant. The association between smoking and abnormal glucose tolerance (AGT) remains controversial. Therefore, the aim of this study was to examine the relationship between smoking prior to and during pregnancy and risk of AGT. Methods We utilized data from a prospective cohort of 1,006 Hispanic (predominantly Puerto Rican) prenatal care patients in Western Massachusetts. Women reported pre- and early pregnancy smoking at recruitment (mean = 15 weeks) and mid pregnancy smoking at a second interview (mean = 28 weeks). AGT was defined as > 135 mg/dL on the routine 1-hour glucose tolerance test (1-hr OGTT). We used multivariable regression to assess the effect of pre, early, and mid-pregnancy smoking on risk of AGT and screening plasma glucose value from the 1-hr OGTT. Results In age-adjusted models, women who smoked > 0-9 cigarettes/day in pre-pregnancy had an increased risk of AGT (OR = 1.90; 95% CI 1.02-3.55) compared to non-smokers; this was attenuated in multivariable models. Smoking in early (OR = 0.48; 95% CI 0.21-1.10) and mid pregnancy (OR = 0.38; 95% CI 0.13-1.11) were not associated with AGT in multivariable models. Smoking during early and mid pregnancy were independently associated with lower glucose screening values, while smoking in pre-pregnancy was not. Conclusions In this prospective cohort of Hispanic women, we did not observe an association between smoking prior to or during pregnancy and risk of AGT. Findings from this study, although based on small numbers of cases, extend prior research to the Hispanic population.

Background C-reactive protein (CRP) during pregnancy has been associated with adverse maternal outcomes such as preeclampsia and gestational diabetes mellitus. Randomized trials suggest that exercise programs may be associated with reductions in CRP in non-pregnant populations; however, such studies have not been conducted among pregnant women. The purpose of this study was to evaluate the impact of an individually-tailored motivationally-matched exercise intervention on CRP in pregnant women. Methods The Behaviors Affecting Baby and You study was a randomized controlled trial of prenatal physical activity to prevent the development of gestational diabetes mellitus in women at increased risk. Women were randomized to either a 12-week exercise intervention (n = 84) or a comparison health and wellness intervention (n = 87). High sensitivity CRP (mg/dL) was measured using a commercial immunoassay kit. Physical activity was measured using the Pregnancy Physical Activity Questionnaire. Mixed model analyses were used to evaluate the impact of the intervention on change in CRP using an intent-to-treat approach. Results CRP decreased (−0.09 mg/dL, 95 % CI: −0.25, 0.07) from pre- to post-intervention in the exercise arm (p = 0.14) and increased (0.08 mg/dL, 95 % CI: −0.07, 0.24) (p = 0.64) in the health and wellness arm; however the between group difference was not statistically significant (p = 0.14). Findings did not differ according to ethnic group or pre-pregnancy body mass index. In a secondary analysis based on self-reported physical activity, women who decreased their time spent in sports/exercise experienced a mean increase in CRP (0.09 mg/dL, 95 % CI: −0.14, 0.33), whereas women who maintained or increased their sports/ exercise experienced a mean decrease in CRP (−0.08 mg/dL, 95 % CI: −0.23, 0.08) (p = 0.046). Conclusions Findings from this randomized trial in an ethnically and socio-economically diverse population of pregnant women were consistent with a positive impact of the exercise intervention on CRP levels, but not of statistical significance. Clinical trial registration ClinicalTrials.gov: NCT00728377. Registered 2 August 2008.