An interim analysis of a gestational weight gain intervention in military personnel and other TRICARE beneficiaries

Overweight/obesity, gestational weight gain, postpartum weight retention, and maternal/neonatal complications in the military

OBJECTIVE

The objective of this study was to examine the prevalence of overweight/obesity and excessive gestational weight gain (GWG) among military beneficiaries and to assess associations of these risk factors with maternal/neonatal complications and substantial postpartum weight retention (PPWR).

METHODS

We obtained data for 48,391 TRICARE beneficiaries who gave birth in 2018 or 2019 in the United States. We used logistic regression and ANOVA to examine relationships among overweight/obesity, GWG, maternal/neonatal complications, and substantial PPWR.

RESULTS

Most TRICARE beneficiaries (75%) had excessive GWG, and 42% had substantial PPWR. Dependents were less likely than active-duty women to have excessive GWG (odds ratio [OR] = 0.73, 95% CI: 0.60-0.88). Women with excessive GWG were three times more likely to have substantial PPWR (OR = 3.57, 95% CI: 3.14-4.06). Those with excessive GWG were more likely to have maternal/neonatal complications (e.g., pregnancy-induced hypertension, cesarean delivery).

CONCLUSIONS

Excessive GWG is frequent among TRICARE beneficiaries, particularly active-duty personnel, and is strongly associated with costly maternal/neonatal complications. Substantial PPWR is also common in this population, with excessive GWG as a key risk factor.

Digital health interventions for all? Examining inclusivity across all stages of the digital health intervention research process

Digital interventions offer many possibilities for improving health, as remote interventions can enhance reach and access to underserved groups of society. However, research evaluating digital health interventions demonstrates that such technologies do not equally benefit all and that some in fact seem to reinforce a "digital health divide." By better understanding these potential pitfalls, we may contribute to narrowing the digital divide in health promotion. The aim of this article is to highlight and reflect upon study design decisions that might unintentionally enhance inequities across key research stages-recruitment, enrollment, engagement, efficacy/effectiveness, and retention. To address the concerns highlighted, we propose strategies including (1) the standard definition of "effectiveness" should be revised to include a measure of inclusivity; (2) studies should report a broad range of potential inequity indicators of participants recruited, randomized, and retained and should conduct sensitivity analyses examining potential sociodemographic differences for both the effect and engagement of the digital interventions; (3) participants from historically marginalized groups should be involved in the design of study procedures, including those related to recruitment, consent, intervention implementation and engagement, assessment, and retention; (4) eligibility criteria should be minimized and carefully selected and the screening process should be streamlined; (5) preregistration of trials should include recruitment benchmarks for sample diversity and comprehensive lists of sociodemographic characteristics assessed; and (6) studies within trials should be embedded to systematically test recruitment and retention strategies to improve inclusivity. The implementation of these strategies would enhance the ability of digital health trials to recruit, randomize, engage, and retain a broader and more representative population in trials, ultimately minimizing the digital divide and broadly improving population health.

A Postpartum Weight Loss-focused Stepped-care Intervention in a Military Population: A Randomized Controlled Trial

OBJECTIVE

Postpartum weight retention is associated with adverse health among both civilian and military women.

PURPOSE

The current study evaluated a stepped-care weight management intervention, Moms Fit 2 Fight, adapted for use in a pregnant and postpartum military population.

METHODS

Active duty women and other TRICARE beneficiaries (N = 430) were randomized to one of three conditions: gestational weight gain only (GWG-only) intervention (n =144), postpartum weight loss only (PPWL-only) intervention (n =142), or a combined GWG + PPWL intervention (n = 144). Those participants who received the PPWL intervention (i.e., the PPWL-only and GWG+PPWL conditions) were combined consistently with the pre-registered protocol and compared to those participants who did not receive the PPWL intervention in the primary analyses. Primary outcome data (i.e., postpartum weight retention) were obtained at 6-months postpartum by unblinded data collectors, and intent-to-treat analyses were conducted.

RESULTS

Retention at 6-months postpartum was 88.4%. Participants who received the PPWL intervention retained marginally less weight (1.31 kg) compared to participants that received the GWG-only intervention (2.39 kg), with a difference of 1.08 kg (p = .07). None of the measured covariates, including breastfeeding status, were significantly associated with postpartum weight retention. Of the participants who received the PPWL intervention, 48.1% participants returned to their pre-pregnancy weight at 6-months postpartum, with no significant differences compared to those who received the GWG-only intervention.

CONCLUSIONS

A behavioral intervention targeting diet and physical activity during the postpartum period had a trend for reduced postpartum weight retention.

CLINICAL TRIAL INFORMATION

The trial is registered on clinicaltrials.gov (NCT03057808).

Gestational Weight Gain During the COVID-19 Pandemic

INTRODUCTION

Healthy gestational weight gain (GWG) is associated with improved pregnancy and delivery outcomes. The COVID-19 pandemic changed eating behaviours and physical activity, and thus may have impacted GWG. This study examines the impact of the COVID-19 pandemic on GWG.

METHODS

Participants (N = 371, 86% of the larger study) were part of a study focused on GWG among TRICARE beneficiaries (i.e., active-duty military personnel and other beneficiaries). Participants were randomized to two treatment groups (GWG intervention (n = 149 pre-COVID and n = 98 during COVID), and usual care condition (n = 76 pre-COVID and n = 48 during COVID). GWG was calculated as the difference between screening weight and at 36 weeks gestation. Participants who delivered prior to the COVID-19 pandemic (March 1, 2020, N = 225) were compared to participants whose pregnancies occurred during the pandemic (N = 146).

RESULTS

We found no significant difference in GWG between those who delivered prior to the pandemic (11.2 ± 4.3 kg) and those whose pregnancies occurred during COVID-19 (10.6 ± 5.4 kg), with no effect of intervention arm. While excessive GWG was higher pre-COVID (62.8%) than during the pandemic (53.7%), this difference was not significant overall or by intervention arm. In addition, we found lower attrition during the pandemic (8.9%) than in the pre-COVID period (18.7%).

DISCUSSION

In contrast to prior research that indicated challenges with engaging in health behaviors during the COVID-19 pandemic, we found that women did not have increased GWG or higher odds of excessive GWG. This research contributes to our understanding of how the pandemic impacted pregnancy weight gain and engagement in research.

Changes in self-reported and accelerometer-measured physical activity among pregnant TRICARE Beneficiaries

Background

Physical activity is recommended for all pregnant individuals and can prevent excessive gestational weight gain. However, physical activity has not been assessed among military personnel and other TRICARE beneficiaries, who experience unique military lifestyles. The current study assessed physical activity among pregnant TRICARE beneficiaries, both active duty and non-active duty, as measured by accelerometry and self-report data to examine potential predictors of physical activity engagement in the third trimester, and if self-report data was consistent with accelerometry data. We expected having a lower BMI, being active-duty, and having higher baseline physical activity engagement to be associated with higher physical activity at 32-weeks. We also hypothesized that accelerometry data would show lower physical activity levels than the self-reported measure.

Methods

Participants were 430 TRICARE adult beneficiaries (204 Active Duty; 226 non-Active Duty) in San Antonio, TX who were part of a randomized controlled parent study that implemented a stepped-care behavioral intervention. Participants were recruited if they were less than 12-weeks gestation and did not have health conditions precluding dietary or physical activity changes (e.g., uncontrolled cardiovascular conditions) or would contribute to weight changes. Participants completed self-report measures and wore an Actical Activity Monitor accelerometer on their wrist to collect physical activity data at baseline and 32-weeks gestation.

Results

Based on the accelerometer data, 99% of participants were meeting moderate physical activity guidelines recommending 150 min of moderate activity per week at baseline, and 96% were meeting this recommendation at 32-weeks. Based on self-report data, 88% of participants at baseline and 92% at 32-weeks met moderate physical activity recommendations. Linear regression and zero-inflated negative binomial models indicated that baseline physical activity engagement predicted moderate physical activity later in pregnancy above and beyond BMI and military status. Surprisingly, self-reported data, but not accelerometer data, showed that higher baseline activity was associated with decreased vigorous activity at 32-weeks gestation. Additionally, self-report and accelerometry data had small correlations at baseline, but not at 32-weeks.

Conclusions

Future intervention efforts may benefit from intervening with individuals with lower pre-pregnancy activity levels, as those who are active seem to continue this habit.

Trial Registration

The trial is registered on clinicaltrials.gov (NCT 03057808).