Focus Groups with Low Income Pregnant Women
Thomas, M., Vieten, C., Adler, N., Ammondson, I., Coleman-Phox, K., Epel, E., & Laraia, B. (2014). Potential for a stress reduction intervention to promote healthy gestational weight gain: focus groups with low-income pregnant women. Women’s health issues : official publication of the Jacobs Institute of Women’s Health, 24(3), e305-11.
Introduction and Background
The magnitude of the obesity epidemic among women of childbearing age in the U.S. is staggering: 60% of all women ages 20-39 and 40% of pregnant women are either overweight or obese (Yeh and Shelton 2005) with women of lower socioeconomic status (SES) and women of color sharing a greater portion of the burden (Ogden, Carroll et al. 2006). Given the increasing prevalence of obesity among pregnant women, the Institute of Medicine (IOM) recently established new guidelines for gestational weight gain (GWG) according to pre-pregnancy body mass index (BMI). Specifically, these recommendations include a total GWG of 15-25 pounds for overweight women (BMI 25.0-29.9) and 11-20 pounds for obese women (BMI ≥ 30.0) (Rasmussen and Yaktine 2009). Excessive GWG confers risk to the pregnant woman and her fetus. Maternal complications include increased risk of gestational diabetes mellitus (GDM), pre-eclampsia, Cesarean section, maternal mortality (Mamun, Callaway et al. 2011; Norman and Reynolds 2011), and post-partum weight retention (Mamun, Kinarivala et al. 2010; Nehring, Schmoll et al. 2011; Hernandez 2012). For offspring, associated risks include increased rates of obesity in childhood and adulthood (Mamun, O’Callaghan et al. 2009; Schack-Nielsen, Michaelsen et al. 2010), greater potential for developing metabolic syndrome (Boney, Verma et al. 2005), and increased incidence of autism spectrum disorders (O’Higgins, Doolan et al. 2013).
In spite of the importance of healthy GWG, approximately 60% of women gain in excess of the IOM recommendations (Carmichael, Abrams et al. 1997; Webb 2008). The reasons for this “non-compliance” are myriad and have significant policy and practice implications for women’s health. Studies to date show mixed results for dietary and other behavioral interventions designed to reduce excessive GWG (Skouteris, Hartley-Clark et al. 2010; Tanentsapf, Heitmann et al. 2011). A recent review concludes that insufficient research exists to make evidence-based recommendations regarding clinical interventions targeting GWG (Ronnberg and Nilsson 2010). Given the magnitude and scope of problems associated with excessive GWG and the paucity of evidence for effective interventions, new approaches are needed. Since depression has been related to excessive gestational weight gain among low income women (Wright, Bilder et al. 2013), interventions targeting psychological factors alongside dietary change have promise.
Recently, Davis et al. highlighted the overlap of stress, coping, and eating behaviors and hypothesize that these interactions play a critical role in the obesity disparities among women of childbearing age (Davis, Stange et al. 2010). Chronic stress and stress during pregnancy are associated with many of the same maternal and offspring risks as maternal obesity and excessive GWG (Wadhwa 2005; Entringer, Buss et al. 2010; Dunkel Schetter 2011). The public health impact of stress within this population is amplified by the association between increased psychosocial stress and antepartum depression (Jesse and Swanson 2007; Melville, Gavin et al. 2010; Dailey and Humphreys 2011). Thus, the interactions among stress, eating behavior, and GWG warrant further exploration. Several recently published qualitative studies examine various contextual factors related to diet and GWG among low income pregnant women (Goodrich, Cregger et al. 2013; Paul, Graham et al. 2013; Reyes, Klotz et al. 2013). Our study extends this work to ask women specifically about their perceptions of the relationship between stress and eating and their interest in a stress reduction intervention during pregnancy.
Maternal stress may impact GWG by two primary pathways: alteration of maternal psychoneuroendocrine physiology and health-related behaviors such as dietary intake and exercise. There is growing evidence of the relationship between stress and eating behaviors, and the role of the HPA-axis and reward circuitry with increased intake of calorically dense food (Adam and Epel 2007). Non-pregnant women with chronic stress have been found to be more prone to emotional eating and visceral deposition of fat (Tomiyama, Dallman et al. 2011) and reduction in abdominal fat was shown among overweight women who experienced a reduction in stress and cortisol awakening response after participating in mindfulness training (Daubenmier, Kristeller et al. 2011). Furthermore, low income women who report higher levels of stress and depression also have lower quality of dietary intake during the first trimester (Fowles, Stang et al. 2012). There is evidence indicating the effectiveness of stress-reduction interventions during pregnancy to ameliorate negative mood and perceived stress (Beddoe and Lee 2008; Vieten and Astin 2008; Urizar and Munoz 2011), but this has not been extended to the relationship with GWG.
Our research team is developing a mindfulness-based stress reduction and nutrition intervention for low-income, overweight and obese pregnant women to achieve healthy GWG. To inform intervention development, we conducted focus groups with women representative of the target population to elicit information about stress, eating behaviors, weight and other health concerns, and to gain feedback about our proposed intervention. By asking women directly about their lives, we are adding their voices to the theoretical construct of pregnancy as a “window of opportunity” for obesity intervention. Their responses provide critical information from low-income overweight women that should influence the dilemma of weight management in pregnancy.