Pragmatic Randomized Clinical Trial to Limit Weight Gain in Pregnancy and Prevent Obesity

Study Overview
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Brief Summary
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Healthy for Two, Healthy for You (H42/H4U) is an innovative evidence-based pregnancy/postpartum health coach intervention that is remotely-delivered (phone coaching using motivational interviewing, web-based platform, mobile phone behavioral tracking). The aim of this randomized controlled trial (RCT) is to embed H42/H4U into Johns Hopkins prenatal care clinics that serve a racially and economically diverse population, leveraging existing staff as trained health coaches to test its effectiveness and implementation. The investigators hypothesize that women in the H42/H4U arm will have lower gestational weight gain and lower rates of gestational diabetes, without an increase in low birth weight infants, and that implementation into the investigators' prenatal care clinics will be feasible and scalable.

Detailed Description
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Despite two decades of public health efforts to combat obesity, rates continue to rise and racial disparities persist. There is an urgent need to re-focus obesity prevention efforts onto young adults, particularly reproductive age women. 23% of women (vs. 13% of men) gain ≥20 kg from age 18 to 55 years, with the highest weight gain in African American women who gain > 1kg/year. Importantly, weight gain of ≥20 kg is associated with development of type 2 diabetes (DM), other obesity-related comorbidities and greater mortality. For women who become pregnant, pregnancy provides an important opportunity for obesity and DM prevention, as excessive gestational weight gain (GWG) and pregnancy complications [e.g. gestational diabetes (GDM)], increase future DM risk. Promoting healthy GWG through behavioral interventions may prevent these pregnancy complications, but importantly has great potential for long-term, sustainable benefits to prevent postpartum weight retention (PPWR) and future obesity and DM, in women and the women's children. With the publication of the LIFE-Moms consortium's results, there is now strong evidence from efficacy trials showing that limiting GWG is achievable and associated with improved exercise and dietary behaviors. Several notable research gaps and next steps have emerged from the LIFE-Moms' studies, which the investigators address in this pragmatic trial. Because these studies were designed to test the efficacy of behavioral weight management on GWG, interventions were resource intensive (i.e. in-person counseling and with limited online and mobile technologies), without a focus on program implementation and sustainability in routine prenatal care settings and lacking intervention in the vulnerable postpartum period. To address these critical evidence gaps and reduce obesity associated with the pregnancy/postpartum periods, the next step is to integrate and test an evidence-based lifestyle intervention in pregnancy and postpartum that utilizes remote delivery of counseling, enables self-monitoring by patients using mobile and online technologies and supports obstetric providers and clinics to optimize care for women at high risk for obesity and future DM. The investigators' experienced team created and tested Healthy for Two / Healthy for You (H42/H4U). H42/H4U is an innovative evidence-based pregnancy/postpartum health coaching intervention that is remotely-delivered (phone coaching using motivational interviewing + web-based platform + mobile phone behavioral tracking). The aim of this R18 pragmatic randomized controlled trial (RCT) is to embed H42/H4U into prenatal care clinics that serve a racially and economically diverse population, leveraging existing staff as trained health coaches and community health workers (CHWs), to test its effectiveness and implementation. The investigators hypothesize that women in the H42/H4U arm will have lower GWG and lower rates of GDM, without an increase in low birth weight infants, and that implementation into the investigators' prenatal care clinics will be feasible and scalable. The investigators will rigorously test this hypothesis through the following Specific Aims: Aim 1. Test the effectiveness of H42/H4U integrated into prenatal care compared with Usual Care among 380 pregnant and postpartum women enrolled from 6 prenatal clinics on: A. Primary outcome: GWG (37 week minus baseline pregnancy [≤15 week gestation] weight) B. Maternal secondary outcomes: Proportion with excessive GWG; GDM incidence; PPWR at 6 months after delivery C. Infant secondary outcomes: Weight at birth, 4 and 6 months. D. Other outcomes: Maternal health behaviors (diet, physical activity, breastfeeding); Maternal wellness (depression, sleep and stress) Aim 2. Assess organizational factors that impact the implementation of the intervention into prenatal care clinics, including costs of intervention delivery and provider and staff satisfaction to inform future dissemination. A. Provider and staff perspectives, including satisfaction, workflow barriers and potential for sustainability, using qualitative semi-structured interviews (n=15 at baseline and end of study). B. Cost analysis to assess intervention delivery costs and the return on investment (ROI) of H42/H4U. This study will advance a potentially powerful, prenatal care-based strategy to reduce obesity in young adult childbearing women and thereby the intergenerational effects on the women's children. The investigators' interdisciplinary team brings together engaged academic and community-based obstetricians, the investigators' health system's population health program and researchers with experience in developing, testing and implementing behavioral interventions in both pregnant and non-pregnant adults in real world settings to enable wide dissemination. Ultimately, the investigators' goal is to design and produce an effective and scalable behavioral strategy, integrated into clinical practice that will: 1) reduce excessive GWG and its associated pregnancy complications, 2) reduce future obesity, DM and other obesity-related complications in mothers and the mothers' children, and 3) ensure high quality care delivery that prevents obesity and DM through a population health approach to prenatal care.

Official Title
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Healthy for 2/Healthy for U: A Pragmatic Randomized Clinical Trial to Limit Gestational Weight Gain and Prevent Obesity in Johns Hopkins Prenatal Care Practices

Conditions
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Pregnancy Weight Gain, Postpartum Weight Retention, Childhood Obesity, Gestational Diabetes, Overweight and Obesity

Intervention / Treatment
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* Behavioral: Healthy for Two/Healthy for You


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age≥18 Singleton pregnancy ≤15 weeks gestation with documented prenatal weight and height in electronic health record Body mass index ≥ 25.0 kg/m2 English-speaking Has smartphone, laptop or tablet and willing to use it for this study Has email address and willing to use for this study Exclusion Criteria: BMI <25 kg/m2 Multiple fetuses History of pre-gestational Type 1 or Type 2 diabetes or taking diabetes medication for treatment of diabetes prior to first prenatal visit Prior history of severe preeclampsia, pre-term birth (< 32 weeks gestation) Poorly controlled blood pressure (> 160/100 mmHg) Substance use disorder or positive urine toxicology (except for THC) for illicit substances (screening done as part of routine care) Psychiatric hospitalization in last 12 months or diagnosis of severe mental illness that is not well controlled Active diagnosis of an eating disorder Unable to walk 1 block without pain or shortness of breath No email address Unable to speak or read in English Planning to move in next 12 months

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Healthy for Two/Healthy for You (H42/H4U)<br>Those assigned to the intervention group will receive the H42/H4U health coaching intervention during pregnancy and 12 weeks postpartum. | Behavioral: Healthy for Two/Healthy for You<br>*  10 month (early pregnancy to 12 weeks postpartum), remotely-delivered, behavioral lifestyle intervention including health coach contacts (via phone, videoconference, and email/MyChart) and an interactive web-based platform.<br>* Other names: H42/H4U;|
| No Intervention: Usual Care Comparison Group: Maintain Health in Pregnancy (mHIP)<br>Those assigned to the Usual Care comparison group, mHIP, will receive typical, evidence- and guideline-based experience in the prenatal care clinics. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total gestational weight gain | Difference between weight (lbs) at 37 weeks and baseline first trimester weight, measured prior to 15 weeks gestation. | At 37 weeks in pregnancy | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants who gained excess weight | Number of participants who gained above the Institute of Medicine recommended weight gain goal. | At 37 weeks in pregnancy | 
| Incidence of gestational diabetes mellitus | Defined and validated by electronic health record diagnosis. | At 37 weeks in pregnancy | 
| Postpartum weight retention | Difference between baseline (≤ 15 weeks gestation weight) and 6 month post delivery maternal weight (lbs). | 6 months after delivery | 
| Infant weight | Weight (lbs) of infant assessed by electronic health record. | At 6 months of age | 
| Proportion of low birth weight infants | Proportion of infants weighing < 2500 grams at birth. | At time of birth/delivery |