Carol M Devine’s research while affiliated with Cornell University and other places

Objective Although life events are clearly important to health, most of the scientific focus has been on baseline life events that occur prior to a study. Life events that occur after enrolment, that is, interval life events, have had almost no attention. The aim of this analysis of data was to develop a method for measuring interval life events that could be used in clinical trials and other longitudinal studies. Design Small Changes and Lasting Effects (SCALE) was a 12-month weight-loss randomised controlled trial (RCT). This was an analysis of the SCALE follow-up data. Setting Healthcare networks, outpatient clinics and community churches in the South Bronx and Harlem areas of New York City. Participants Overweight black and Latino adults. This analysis focuses on the 330 of the 405 patients who had >4 weeks of follow-up with at least one perceived stress score (PSS). Intervention The SCALE RCT was published elsewhere and involved positive affect and self-affirmation to increase behaviour change. Outcome 5% weight loss. Follow-up Over 12 months, up to 27 follow-ups were conducted that evaluated interval life events, eating and physical activity behaviour, weight and perceived stress. During these follow-ups, participants were asked two open-ended questions to capture interval life events. The interval life events were qualitatively coded into categories. The interval life events categories were compared with interval monthly measures of perceived stress using the 4-item PSS scale. Results During the interval follow-ups for the RCT, 70.6% of the 330 patients reported at least one interval life event, which occurred during a median of 15 follow-ups (95% CI: 5 to 24). The median number of interval events was 2 (95% CI: 0 to 8): 30.6% reported their own illness; 22%, death or bereavement; 21.8%, illness in the family and 13.1%, family conflicts. The mean perceived stress score (PSS-4) assessed over the year of follow-up was 3.2±2.7. Mean perceived stress (PSS-4) increased, especially for interval financial events, major conflict with a partner and unemployment, but by less for deaths, family illness and family conflict. Participants with the most interval life events had the greatest increase in interval perceived stress (p<0.0001). Of note, neither high baseline perceived stress (PSS-10 >20) nor baseline depression (Patient Health Questionnaire-9 >10) were associated with higher interval life events (p>0.05); but those with lower social support had more events. However, those with either depression or stress had higher interval stress responses. Most participants had neither baseline nor interval events, and the percentage with both was small so that baseline events did not predict subsequent perceived stress. Conclusions This method provides a straightforward method of assessing interval life events, by asking two open-ended questions, that can be coded in a simple categorical framework. Such events can affect outcomes in longitudinal studies and trials in part by increasing perceived stress. This framework moves beyond the events identified as important in the 1950s and recognises that specific life events may have significantly different life impacts in different individuals. Trial registeration number NCT01198990 ; Post-results.

Objective To understand how changes in low-income mothers’ work, home, and childcare environments impact their food practices for young children. Methods The grounded theory, theory-guided, design included two in-depth qualitative interviews (6 to 8 months apart) with each of 19 low income, working/student mothers of Head Start children, living in a rural county in Upstate New York. Interviews covered mothers’ experiences of employment, school, family, household, and childcare events over one school year and whether and how events changed child food practices. Emergent themes related to mothers’ experiences of life events, with attention to influences on child food practices, were open-coded using a constant comparative approach. A life course approach and a transactional model of the stress process informed interpretation. Results Within the study period, most mothers reported at least one life event, with many experiencing one or more changes in employers, job schedules, residence, household members, or childcare situation. Emergent patterns of adjustment in child food practices linked with life events were shaped by mothers’ appraisals of life events, the availability of coping resources, and their adaptations to events, based on temporal, financial, and social resources. The findings support a view of child feeding informed by the transactional model of stress. Conclusions Instability in work, family, household, and childcare highlight changing contexts for child food practices in daily life. Research and practice should acknowledge the changing nature of the child feeding context and the need for children’s caregivers to make adjustments in response to changing resources.

Understanding the influence of the food environment on eating behaviors is important for addressing spatial health disparities. This research aimed to understand how Dominican-born women living in New York City interacted with their food environments. Nineteen women participated in qualitative interviews. Study participants described food activity footprints, a new measure of individualized food environment that accounted for the spatial and temporal environments. Findings indicated that researcher-defined food environment may not represent perceived food access and that the temporal environment was a driving force in dietary behavior. Therefore, food activity footprints may provide additional insight factors influencing health disparities.

Life course perspective provides a framework for examining the immigrant experience within the context of globalization and transnationalism. Life course perspective states that individuals develop food choice trajectories based on childhood experiences with food. This study examined the influence of childhood experiences and life events on eating behaviors of Dominican born women in Santo Domingo, Dominican Republic, and New York City. Findings revealed that women developed traditional or non-traditional food choice trajectories. These food choice trajectories remained stable through transition points, such as immigration, marriage, and divorce. Women discussed changes in the amount of food that was eaten, which may explain weight gain after immigration. These findings highlight the limitations of acculturation theory in understanding the eating behaviors of immigrants and provide an alternative explanation for weight gain after immigration.

Behavioral weight loss interventions (BWLIs) that promote healthy eating as a way to achieve and maintain healthy weights do not work for most people. Most participants encounter significant challenges to behavior change and do not lose weight or maintain meaningful weight loss. For some, there may be negative consequences of participating in a BWLI, including social, psychological and economic costs. The literature is largely silent on these negative unintended consequences, but they are important for both practical and ethical reasons. If efforts to eat healthier have too many negative consequences for individuals and groups, then these efforts are unlikely to be effective, and promoting them may not always be ethical; this would boost the case for moving away from individual-focused efforts as part of healthy eating efforts. Alternatively, if we can make BWLI interventions more effective and more ethical by mitigating these unintended consequences, then it may be too soon to give up on individual-focused efforts. We make a case for systematic assessment and reporting of the unintended consequences of BWLI. This could contribute to more effective and ethical BWLI and inform obesity interventions and policies more broadly.

Significant changes in work and family conditions over the last three decades have important implications for understanding how young children are fed. The new conditions of work and family have placed pressures on families. The aim of this study was to explore the work and family pressures shaping the ways parents feed their young children on a day-to-day basis. Twenty-two purposively recruited low-income employed mothers of 3–4 year old children from a rural county Head Start program in Upstate New York reported details about the context of their children's eating episodes in a 24-h qualitative dietary recall. Participating mothers were employed and/or in school at least 20 h a week and varied in partner and household characteristics. Interview transcripts were open coded using the constant comparative method for usual ways of feeding children. A typology of three emergent child feeding routines was identified based on mothers' accounts of the recurring ways they fed their child. Mothers' feeding routines were distinguished by a combination of four recurring key strategies – planning ahead, delegating, making trade-offs, and coordinating. Work schedule predictability and other adults helped mothers maintain feeding routines. Unexpected daily events, such as working overtime or waking up late, disrupted child feeding routines and required modifications. These findings suggest that understanding how young children are fed requires recognizing the socio-ecological environments that involve working mothers' daily schedules and household conditions and the multiple ways that mothers manage food and feeding to fit environmental constraints. There is a need to look at more than just family meals to understand parents' daily strategies for feeding young children and their implications for child nutrition.

Objective: To evaluate the efficacy of a small change behavioral weight loss intervention with or without a positive affect/self-affirmation (PA/SA) component on weight loss at 12 months. Methods: Black and Hispanic adults (N = 405) with body mass index 25-50 kg/m(2) selected one of ten small change eating strategies and a physical activity goal, randomly with/without PA/SA. Participants were followed by community health workers at set intervals (weekly in months 1-3; biweekly in months 4-9; once monthly in months 10-12). Results: There was no difference in weight loss at 12 months between participants in the small change approach alone (1.1%) versus the small change PA/SA intervention (1.2%). During treatment, 9% of participants lost at least 7% of their initial body weight. Participants who reported more interval life events had a lower likelihood of losing weight (P < 0.0001). However, those randomized to the small change PA/SA intervention gained less weight (+0.3% vs. 2.3% gain; P < 0.0001). Conclusions: The small change PA/SA intervention did not lead to a significant difference in weight loss in comparison to the small change approach alone. It did, however, decrease the negative impact of psychosocial stressors on weight gain among participants with more interval life events.

Objective: Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training. Design: Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models. Setting: An online course for participants in the USA and abroad. Subjects: Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240). Results: One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05). Conclusions: Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.

Obese women are at risk for shorter breastfeeding duration, but little is known about how obese women experience breastfeeding. The aim of this study was to understand obese women's breastfeeding experiences. We enrolled pregnant women in upstate New York, who were either obese [n = 13; body mass index (BMI) ≥30 kg/m2] or normal weight (n = 9; BMI 18.5–24.9 kg/m2) before conception and intended to breastfeed. A longitudinal, qualitative study was conducted from February 2013 through August 2014 with semi-structured interviews during pregnancy and at specific times post-partum through 3 months. Interviews were audio recorded, transcribed and analyzed using content analysis. Themes that emerged in analysis were compared between obese and normal-weight women. Differences were identified and described. Prenatally, obese women expressed less confidence about breastfeeding than normal-weight women. Post-partum, obese women and their infants had more health issues that affected breastfeeding, such as low infant blood glucose. Compared with normal-weight women, they also experienced more challenges with latching and positioning their infants. Breastfeeding required more time, props and pillows, which limited where obese women could breastfeed. Obese women also experienced more difficulty finding nursing bras and required more tangible social support than normal-weight women. In conclusion, obese women experienced more challenges than women of normal weight; some challenges were similar to those of normal-weight women but were experienced to a greater degree or a longer duration. Other challenges were unique. Obese women could benefit from targeted care prenatally and during the hospital stay as well as continued support post-partum to improve breastfeeding outcomes.