OBEAT - Beating Obesity

OBEAT - Beating Obesity: A Feasibility Trial

The primary objective of this trial is to study the feasibility of a resilience intervention to reduce stress and thus improve sleep, healthy diet and physical activity in normal weight pregnant women.

Initially, an exploratory study of stressors and worrying in pregnant women will be done by use of qualitative methods (focus group interviews) followed by a randomised controlled feasibility trial with a parallel qualitative process evaluation.

This project is expected to improve the understanding of the processes and feasibility of conducting a randomized intervention study to examine if improvements in chronic stress and poor sleep during pregnancy improves early weight gain and childhood risk of obesity.

Study Overview

• Status: Completed
• Conditions: Stress; Pregnancy Related; Obesity, Childhood
• Intervention / Treatment: Behavioral: Resilience program

Detailed Description

Phase 1: Planning In Phase 1 (6 months), the project will be developed and planned, and approvals from the Danish Data Protection Agency and Ethical Committee of the Capital Region to conduct the study will be obtained.

Validated questionnaires to measure perceived stress, sleep patterns, physical activity- and dietary habits will be selected and pilot tested.

Phase 2: Recruitment and data collection In Phase 2 (12 months), participants will be recruited and randomized. Pregnant women living in Denmark are offered public, antenatal care delivered by hospital employed midwives. Healthy, non-obese, pregnant women assigned to antenatal care and birth at Hvidovre Hospital, are routinely invited to a first antenatal midwife session at gestational week 14-18. At these sessions, participants will be informed and recruited to the feasibility study. In 8 weeks approximately 240 pregnant women will be eligible, thus 120 women corresponding to 50% of all eligible pregnant women in one month will be recruited. In this feasibility study 50% of the women will be randomised to the intervention group and introduced to the resilience internet-based program/ smart phone app and 50% will be randomised to the control group and receive standard care. Computer-based randomization procedures will be used.

Phase 3: Feasibility study evaluation In Phase 3 (19 months), the knowledge obtained in Phase 2 will be evaluated.

An effect evaluation of the project will be conducted by analysing the collected clinical data, primarily related to changes and correlations in chronic stress in mother and infant (measured by hair cortisol), perceived stress, physical activity- and dietary habits, infant birth length and weight, and gestational age.

A process evaluation will also be conducted. The Committee of Health Education will collect data on how much and what parts of the resilience program has been used by the participating pregnant women. In addition, the participants will be asked to complete a short questionnaire on how frequent and how satisfied they have been with using the program. The researchers also want to use qualitative focus group interviews to investigate the participants' attitudes and acceptability of the proposed intervention.

The results of the effect- and process evaluations will be synthesized and will, depending on the results of the feasibility study, be implemented in a following planning of a large RCT.

Qualitative analytical methods The interview guide will be developed based on a literature search of existing literature in the field. To minimize the bias of my own influence I will consider my own experience and pre-understanding as a midwife.

The interviews will be recorded digitally and subsequently transcribed literally. The data will be analyzed using content analysis as described by Graneheim & Lundman. The purpose of the content analysis is to organize and understand the meaning of the data collected in the focus group interviews and to draw conclusions from it.

Statistical analysis The clinical outcomes will be examined using paired t-tests as well as linear or logistic regression analyses. Analyses will be done crude and adjusted for potential confounders obtained from the completed questionnaires. Results of the analyses of the clinical outcomes are expected to be underpowered due to the feasibility design of this study but will however provide estimates indicating any direction or effect size of the resilience program on this target group.

• Study Type: Interventional
• Enrollment (Actual): 124
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Denmark
  • Frederiksberg, Denmark, 2000
    • Frederiksberg Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 50 years (Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Expecting first child
• Speaks Danish
• Non-obese (BMI < 30)
• Singleton pregnancy
• Visited to basic level midwife care

Exclusion Criteria:

• Non-danish speakers
• Type 1 or 2 diabetes
• Visited to specialist midwife care for psychosocial reasons
• Expecting twins
• BMI > 30
• Multipara

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Resilience program; The resilience program consists of different modules that are based on research on mentalization, mindfulness, parent management training, improving self-control and self-efficacy, cognitive behaviour therapy, social learning theory and neuroscience. The MyResilience program is also informed by cognitive bias modification and self-control training research. These techniques have been found to be effective in improving engagement in health behaviours and reducing symptoms and negative behaviours in clinical groups	Behavioral: Resilience program; The resilience program consists of different modules that are based on research on mentalization, mindfulness, parent management training, improving self-control and self-efficacy, cognitive behaviour therapy, social learning theory and neuroscience. The MyResilience program is also informed by cognitive bias modification and self-control training research. These techniques have been found to be effective in improving engagement in health behaviours and reducing symptoms and negative behaviours in clinical groups
No Intervention: Standard care; Danish antenatal standard care is 3 visits at the general practitioner, 5 midwife controls and 2 ultrasound scans

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recruitment-rates - feasibility	Number of participants out of eligible pregnant women approached	Two months after birth
Recruitment-time - feasibility	Number of days used to recruit the decided number of 120 participants	Two months after birth
Attrition-rates - feasibility	Number of participants leaving the study before the end	Two months after birth
Follow up-rates - feasibility	Number of participants in final clinical examination	Two months after birth
Compliance-rates - feasibility	Use of resilience program measured from web-statistics	Two months after birth
Self-reported compliance-rates - feasibility	Use of resilience program from patient-reported questionnaire	Two months after birth
Satisfaction-rates - feasibility	Measured from patient-reported questionnaire	Two months after birth

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in maternal chronic stress	Assessed by level of cortisol (ng/ml) in 3 cm scalp hair	Gestational week 14-18, 28, 35, birth and two months after birth
Change in maternal perceived stress	Assessed by Cohen's Perceived Stress Scale (PSS). PSS measures the respondent's experience of stress over the past four weeks using ten questions to answer to what extent the respondent experiences his life as unpredictable, uncontrollable and stressful, and whether he or she feels nervous or stressed. The scale goes from 0 to 40. The higher the score, the higher the level of stress experienced.	Gestational week 14-18, 28, 35 and two months after birth
Change in maternal depression, anxiety and tension/stress.	Assessed by The Depression and Anxiety Stress Scale (DASS). DASS is a 42-item self report instrument designed to measure the three related negative emotional states of depression, anxiety and tension/stress. The scale goes from 0 to 42 for every emotional state. The higher the score, the higher the level of depression, anxiety or stress experienced. Range: Stress: Normal 0-10, Mild 11-18, Moderate 19-26, Severe 27-34, Extremely severe 35-42. Anxiety: Normal 0-6, Mild 7-9, Moderate 10-14, Severe 15-19, Extremely severe 20-42. Depression: Normal 0-9, Mild 10-12, Moderate 13-20, Severe 21-27, Extremely severe 28-42.	Gestational week 14-18, 28, 35 and two months after birth
Change in mentalization ability	Assessed by the Reflective Functioning Questionnaire, which comprises eight items and includes two subscales: Certainty (RFQc) and uncertainty (RFQu) about mental states. The 7 point Likert scale contains answers ranging from strongly disagree to strongly agree. Of the 6 items on each subscale, two are unique and four shared across the two scales. With the RFQc subscale, strong disagreement reflects hypermentalizing, and agreement to any degree (or a neutral response) reflects more genuine mentalizing (acknowledging the opaqueness of mental states). With the RFQu subscale, high agreement scores reflect a stance characterised by a lack of knowledge about mental states, or 'hypo-mentalizing', and lower scores represent an acknowledgement of the opaqueness of mental states, a characteristic of good mentalizing. Both scales are based on a mean of the 6 items (Cucchi et al. (2018), PeerJ, DOI 10.7717/peerj.5756).	Gestational week 14-18, 28, 35 and two months after birth
Changes in maternal Sense of Coherence (SOC)	Assessed by Antonovsky's 13-item SOC scale, which measures comprehensibility (5 items), manageability (4 items), and meaningfulness (4 items). Each item has seven graded (Likert-type) response scale, which is summed up and the total scores can range from 13 (low SOC) to the maximum of 91 (highest possible SOC).	Gestational week 14-18, 28, 35 and two months after birth
Changes in maternal resilience	Assessed by the Connor-Davidson Resilience Scale (CD-risc). The scale comprises of 25 items, each rated on a 5-point scale (0-4). The total score ranges from 0-100, with higher scores reflecting greater resilience.	Gestational week 14-18, 28, 35 and two months after birth
Differences in parental stress	Assessed by The Parental Stress Scale (PSS). PSS is made up of 18 items rated on a Likert- type 5-point scale that describes the parent-child relationship and how each parent feels about it. A higher score indicates a higher level of parental stress.	Two months after birth
Changes in fear of childbirth	Fear of childbirth is assessed asking the question 'Are you anxious about the course of the upcoming delivery?' in a participant-reported questionnaire. Possible responses are: 'Not at all', 'A little' or 'A lot'. Only the last response is considered to represent fear of childbirth.	Gestational week 14-18, 28, 35
Changes in fetal health anxiety	Fetal health anxiety is assessed asking the question 'Are you anxious about the health of the expected child?' in a participant-reported questionnaire. Possible responses are: 'Not at all', 'A little' or 'A lot'. Only the last response is considered to represent fetal health anxiety.	Gestational week 14-18, 28, 35
Sleep patterns - mother	Self-reported sleep duration and sleep quality measured from participant-reported questionnaire	Gestational week 14-18, 28, 35 and two months after birth
Changes in participant's physical activity - transportation	Self-reported means of transportation (biking, public transportation, car, walking) in hours pr. week	Gestational week 14-18, 28, 35 and two months after birth
Changes in participant's physical activity - exercise	Self-reported exercise (i.e. dancing, yoga or badminton) in hours pr. week	Gestational week 14-18, 28, 35 and two months after birth
Changes in diet - mother	Measured with a Food Frequency Questionnaire (FFQ) developed for the Danish National Birth cohort is used for dietary assessment. Most questions focus on the dietary habits during the 4 weeks prior to completion of the questionnaire, but a number of questions address changes in dietary habits during pregnancy. The FFQ includes questions on intake of 360 food and beverage items in the previous 4 weeks and is validated with a 7-day weighted food record. The 360 food items recorded in the FFQ are aggregated into 36 food groups and, together with the daily intake (in grams) for each food group, eaten by a given individual, are used to identify dietary patterns.	Gestational week 14-18, 28, 35 and two months after birth
Weight - mother	Maternal weight (kg) measured at midwife sessions	Gestational week 14-18, 28, 35 and two months after birth
Weight - child	Weight (kg), obtained from birth records and clinical examination	Birth and two months after birth
Length - child	Length (cm) obtained from birth records and clinical examination	Birth and two months after birth
Head circumference - child	Head circumference (cm) obtained from birth records and clinical examination	Birth and two months after birth

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Diet - infant (breastfeeding, bottlefeeding)	Measured from participant-reported questionnaire	Two months after birth
Infant crying	Measured from participant-reported questionnaire in hours of crying pr. day	Two months after birth
Differences in infant chronic stress	Level of cortisol (ng/ml) in 3 cm scalp hair	Birth and two months after birth
Differences in birth method	Vaginal birth, elective cesarean og acute cesarean obtained from birth records	Birth
Differences in epidural-rate	Epidural as pain relief during birth from birth records	Birth
Differences in rates of prolonged labour	Use of oxytocin-drip during birth from birth records	Birth
Differences in use of private healthcare providers	Yes/no in participant-reported questionnaire	Gestational week 14-18, 28, 35, birth and two months after birth
Differences in absence from work during pregnancy	Reasons to absence (i.e. pregnancy complications) and number of days absent in participant-reported questionnaire	Gestational week 14-18, 28, 35

Collaborators and Investigators

• Sponsor: Bispebjerg Hospital
• Collaborators: Hvidovre University Hospital; TRYG Foundation; Oak Foundation
• Investigators: Principal Investigator: Berit Heitmann, Professor, Research Unit for Dietary Studies at The Parker Institute Bispebjerg and Frederiksberg Hospital

Publications and helpful links

General Publications

• Ladekarl M, Olsen NJ, Winckler K, Brodsgaard A, Nohr EA, Heitmann BL, Specht IO. Early Postpartum Stress, Anxiety, Depression, and Resilience Development among Danish First-Time Mothers before and during First-Wave COVID-19 Pandemic. Int J Environ Res Public Health. 2021 Nov 9;18(22):11734. doi: 10.3390/ijerph182211734.

Study record dates

Study Major Dates

• Study Start (Actual): June 18, 2019
• Primary Completion (Actual): June 25, 2020
• Study Completion (Actual): October 28, 2020

Study Registration Dates

• First Submitted: February 4, 2019
• First Submitted That Met QC Criteria: February 21, 2019
• First Posted (Actual): February 26, 2019

Study Record Updates

• Last Update Posted (Actual): January 21, 2022
• Last Update Submitted That Met QC Criteria: January 20, 2022
• Last Verified: January 1, 2022

More Information

Terms related to this study

• Keywords: Feasibility; Sleep; Cortisol; Resilience; Healthy lifestyle
• Additional Relevant MeSH Terms: Overnutrition; Nutrition Disorders; Overweight; Body Weight; Obesity; Pediatric Obesity
• Other Study ID Numbers: TRYG-125690

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No