Project Title: Improving Outcomes of Childhood Obesity Through Maternal Intervention

Grant Program: Ann A. Hertzler Memorial Research Grant

Proposed Start Date: January 10, 2019
Proposed End Date: June 10, 2020
Funds Requested: $14,987.43
Authors: Leah Fitchett,Valerie Becker, Brianna Fachler, Beverly Iheanacho, Daniela Quiros

Project Director: TACKS Grant Writer

Group 2
Community Nutrition Class
The University of Delaware
000 Little Bob Street
Newark, DE 19711
Phone: (972)123-0567
Email: group2@udel.edu

Authorized Organizational Representative:

Dr. Pacanowski, Professor of Community Nutrition
Department of Behavioral Health and Nutrition
000 Little Bob Street
Phone:(333)137-4692
Email: cpacanow@udel.edu
Academy Research Committee
Abstract:
Childhood obesity remains one of the most pressing concerns of modern healthcare, despite
continuing focus on intervention efforts. Developing novel solutions for the prevention and resolution of
childhood obesity is necessary as the problem not only remains, but continues to escalate. There is
currently a lack of focus on developing systems that use maternal health as a way to influence the
development of childhood obesity. This program aims to narrow that gap by intervening in childhood
obesity at the primary level, by reducing the risk of obesity before it occurs. The intervention is designed
to promote healthy maternal gestational weight gain in order to decrease the risk of high infant birth
weight as a result. A sample of 50 pregnant women identified based on body mass index (BMI) as either
overweight or obese will be recruited from obstetrics and gynecology (OB-GYN) clinics in New Castle
County, Delaware. The intervention portion of the program will provide participants with a 24-week
intervention of nutrition education and fitness classes targeted towards promoting healthy pregnancy.
Participant anthropometrics will be collected once a month from their OB-GYN in order to assess the
progress of gestational weight gain. Pre- and post- assessments on nutrition knowledge and nutrition self-
efficacy will be used to evaluate the success of the nutrition education classes. Following the intervention
stage, infant weights will be gathered once a month, from birth to 11 months, in order to evaluate the
effectiveness of the program.
Introduction:

Obesity is a continuing public health concern as prevalence rates continue to rise and associated

healthcare costs exceed $99 billion a year.1 Increasing rates of both overweight and obesity are pervasive

across factors such as age, race and gender, showing why interventions targeted specifically at childhood

obesity are so important. The prevalence of childhood overweight and obesity in the United States has

been increasing dramatically over the last four decades, reaching its current peak of 18.5% nationally. 1 In

the state of Delaware, 17.2% of children ages 2-4 are considered obese and 30.9% of adolescents ages 10-

19 are considered either overweight or obese.2 This is higher than similar statistics of national obesity

rates, which are reported as 13.9% for 2-5 year olds and 20.6% for 12-19 year olds.1

Causal factors of overweight and obesity have yet to be established, however, links have been

found between maternal overweight and obesity, excess maternal gestational weight gain (GWG) and

higher rates of child overweight and obesity.3, 4, 5 Children with mothers who are obese in their first

trimester of pregnancy have an obesity rate of 24.1%, compared to a rate of 9.0% for children of normal

weight mothers.4 An estimated 40% of pregnant women gain over the recommended quantity of weight

throughout pregnancy, which poses risk for infant outcomes such as increased weight for gestational age,

and greater adiposity.5 These factors in turn have a high level of continuity into childhood and adulthood.

The intervention proposed will be implemented at the individual level of the socioecological

model by targeting pregnant mothers’ individual thoughts, behaviors and attitudes related to dietary

choices and physical activity, as well as promoting nutrition self efficacy. Nutrition self-efficacy for this

program is defined as participants’ confidence in their ability to purchase, prepare and consume healthy

foods. Nutrition education has been shown to effectively improve the nutritional adequacy of dietary

intake for pregnant mothers, and promote appropriate GWG.6, 7 Additionally, moderate to intense physical

activity is also associated with lower risk of excessive GWG.8 The proposed program seeks to address the

issue of childhood obesity by intervening during pregnancy to promote appropriate GWG. The program

combines the use of nutrition education to increase participants’ health knowledge and nutrition self-

efficacy, as well as fitness classes to promote a healthy physical activity throughout pregnancy.
Goals and Objectives:

Goal 1: Increase the nutrition knowledge of pregnant mothers through nutrition education to reduce

excess maternal gestational weight gain. This will ultimately decrease childhood obesity.

Objective A (Process): Nutrition education classes taught by a registered dietitian will be offered

twice a week every other week for 24 weeks. Each class will be 50 minutes long.

Objective B (Outcome): Nutrition knowledge will be increased by at least 50% in 75% of

participants over the course of 24 weeks.

Objective C (Outcome): Self-efficacy of participants will be increased by 50% in at least 75% of

participants by the end of the 24 weeks.

Goal 2: Increase the frequency of physical activity in pregnant mothers to ultimately decrease the risk of

childhood obesity.

Objective A (Process): Offer fitness classes 3 times a week for 24 weeks, tailored to women in

their second and third trimesters of pregnancy. Each fitness class will be 50 minutes long.

Objective B (Outcome): 75% of the women will attend at least 50% of the fitness classes offered

at the end of the 24 weeks.

Objective C (Outcome): 75% of mothers will maintain gestational weight gain within normal

limits throughout their pregnancy. Appropriate gestational weight gain will be determined based

on each participant’s pre-pregnancy BMI.

Goal 3: Promote appropriate infant weight gain.

Objective A (Outcome): 75% of infants will be below the 85th percentile for weight measured at

eleven months postpartum.

Objective B (Process): Weight at eleven months postpartum will be gathered for 90% of infants.

Methods:

The intervention will target expecting mothers between the ages of 20 and 40 who are categorized

as overweight or obese based on calculated body mass index (BMI). The target size of the intervention

will be 50 participants. The full extent of the program will span over 18 months, from January 10, 2019 to
June 10, 2020 (Table 1). Participant recruitment will occur in the first month after funds are allocated,

from January 10th to February 10th. The intervention stage will occur in the 24 weeks following

participant recruitment, from February 11th to August 5th. The final 11 months of the program will be

for collecting data on infant weight and evaluating both infant weight data and intervention data.

Participants will be recruited through letters sent to patients of OB-GYN clinics in the New

Castle County, Delaware area. Recruited participants must be at the end of their first trimester of

pregnancy in order to begin the intervention around the start of the second trimester. Exclusionary criteria

include conditions that prevent safe participation in moderate physical activity, such as heart conditions,

high risk pregnancies, and injuries limiting mobility. Participation must be approved by a primary care

physician.

The intervention will offer 24 total nutrition education classes and 72 total fitness classes.

Nutrition classes will be offered every other week, with the same topic offered two times each week to

accommodate participant schedules. Each class will be 50 minutes long. The classes will run for 24

weeks, offering 12 topics in total (Table 3). A sample lesson plan for the topic of “Introducing Solid

Foods to Your Infant” can be found in Appendix D. Fitness classes will be offered three times a week for

24 weeks, alternating between yoga, strength training and stationary cycling. Fitness classes will be

offered on the same day each week. Yoga will be offered on Mondays, strength training will be offered on

Wednesdays, and stationary cycling will be offered on Fridays. Each class will be 50 minutes long (Table

4). Participants will be required to attend 75% of the education classes offered and 50% of the fitness

classes offered in order for data to be included in the evaluation.

Staffing for this intervention includes one registered dietitian (RD) and three fitness instructors.

Each staff member will be compensated for their participation in the program; $1,248 for the dietitian and

$552 for each fitness instructor.⁹ Nutrition sessions and fitness classes will take place at the University of

Delaware in the Carpenter Sports Building (CSB). Classes will be held in private rooms to ensure

participant confidentiality. Fitness classes will be held in room 171A and nutrition education classes will

be held in 002. Attendance will be taken for every nutrition education and fitness class (Appendix C). Full
participation will be encouraged through financial compensation proportional to how many classes are

attend. Extra compensation will not be given for attending both sessions of the same nutrition education

topic. Therefore, compensation will be based on attendance of 12 total nutrition classes and 72 total

fitness classes. Compensation will be $2.08 per class attended, totaling up to $175 for full participation.

Nutrition education classes will be offered every Tuesday at 4pm and Saturday at 10am starting

February 12th, 2019, and will be taught by a registered dietitian from the University of Delaware. There

will be a total of 24 classes and 12 topics offered. A list of all topics to be offered can be found in Table 3.

Fitness classes will be offered three times a week for 24 weeks beginning February 11th, 2019, and will

be taught by three different CSB staff members, one for each class. There will be a total of 72 fitness

classes, offered on each Monday, Wednesday and Friday at 9am. The classes will have a weekly cycle

alternating between yoga, strength training and stationary cycling (Table 4). All equipment needed for the

fitness classes will be utilized from CSB.

Following the intervention, infant weight will be collected once a month from each infant’s

primary care physician up until 11 months postpartum and compared to World Health Organization

(WHO) growth charts. Data collected from mothers and infants and will be evaluated by researchers using

SPSS statistical software.

Evaluation:

In order to assess baseline nutrition knowledge, a pre-assessment measuring both nutrition

knowledge and nutrition self-efficacy will be administered by researchers at the start of the intervention

(Appendix A). Baseline physical activity level will be assessed with a separate pre-assessment (Appendix

B). The RD will be assigned to conduct nutrition education classes, and will be responsible for recording

dates, times and topics of education classes given, as well as completing timesheets that must be handed

in before the RD is compensated. Participants’ attendance of nutrition education classes will be collected

weekly by the RD using attendance sheets that participants are required to sign (Appendix C). Instructors
will facilitate fitness classes and complete a timesheet to verify that classes were offered each week.

Participants’ attendance of fitness classes will be collected weekly by fitness instructors using the same

attendance sheet in Appendix C. Participant weight will be obtained from their OB-GYN clinics once a

month. At the end of the intervention, researchers will administer post-assessments measuring nutrition

knowledge, nutrition self-efficacy, and physical activity level (Appendix A and B). Post-assessment data

will be compared to pre-assessment data from the beginning of the intervention. Evaluation of the

effectiveness of the intervention will be determined by comparing mothers’ intervention data to infant

weight over 11 months postpartum. Infant weight will be collected once a month from each infant’s

primary care physician and compared to World Health Organization (WHO) growth charts.

Future Funding:

If the program objectives are not met, further research and modifications to the program will be

made. If the intervention is successful, the goal is for the program to be continued with patients at other

healthcare facilities such as hospitals, WIC clinics, and OB-GYN clinics within Delaware. Continued

funding for the intervention will be acquired through federally funded programs like WIC, and other

obesity-related grants to help this become an ongoing program for the future. The hope is to obtain similar

quantities of funding in the future in order to replicate the intervention in a similar manner.
Table 1: Timeline

Stage Timespan Description

Recruitment Month 1 Recruitment will be conducted by program coordinators. Intervention

has a goal of recruiting 50 pregnant women ages 20-40 to participate.
Potential participants will be contacted through letters sent to patients
of OB-GYN offices in the New Castle County area.

Start of Month 2-6 Nutrition and fitness pre-assessments will be administered.

Intervention 24 total nutrition education classes will be offered every other week for
24 weeks, with the same topic offered two times each week. Each class
will be 50 minutes long.
Attendance at each class will be collected.
72 total fitness classes will be offered 3 times a week for 24 weeks.
Yoga will be offered every Monday, strength training will be offered
every Wednesday, and stationary cycling will be offered every Friday.
Attendance at each class will be collected.
Participant weight information will be obtained from OB-GYN clinics
each month.

End of Month 7 Nutrition and fitness post-assessments will be administered.

Intervention

Evaluation Month 8-18 Infant weight will be collected each month post-partum from infants’
physicians.
Data on infant weight will be evaluated based on World Health
Organization (WHO) growth charts.
Effectiveness of the program will be determined based on comparing
infant weight outcomes to measurements collected from mothers
during the intervention stage.
Table 2: Budget

Category Amount

Personnel9 $2,904

24 education classes (1 RD)

- 24 classes X 2 class a week = 48 total classes
- 48 total classes X $26/hour = $1,248

72 fitness classes (3 staff)

- 72 total classes X $23/hour = $1,656

Location (rooms) $2,400

- Room CSB 0021
- $20/session X 48 sessions = $960
- Room CSB 171A
-$20/session X 72 sessions = $1,440

Supplies10 $112.47
- paper: $32.99
- pens: $7.49
- ink: $71.99

Equipment10 $20.99
-food model $20.99

Computer Costs10 $799.97

-Computer: $399.99
-Printer: $99.99
-Projector: $299.99

Monetary reward for participating $8,750

$175 per person X 50 participants

Total: $14,987.43

1
(C. Pacanowski, email communication, October 10, 2018)
Table 3: Nutrition Education Class Schedule

Week-- Tuesday at 4pm & Saturday at 10am Lesson

Week 1 General Overview and macronutrients

Week 3 Grains

Week 5 Protein Foods

Week 7 Fruits

Week 9 Vegetables

Week 11 Dairy

Week 13 Healthy recipes

Week 15 Caloric needs during trimesters/lactation

Week 17 Supplementation

Week 19 Breastfeeding / Formula feeding

Week 21 Introducing solid foods

Week 23 Post pregnancy nutrition

Table 4: Fitness Class Schedule

Fitness Classes (3x/week for 24 weeks)11

Week Fitness Class

MON WED FRIDAY

Week 1 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 2 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 3 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 4 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 5 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 6 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 7 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 8 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 9 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 10 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 11 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 12 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 13 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 14 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 15 Yoga Strength training Stationary cycling

-50 min -50 min -50 min
Week 16 Yoga Strength training Stationary cycling
-50 min -50 min -50 min

Week 17 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 18 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 19 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 20 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 21 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 22 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 23 Yoga Strength training Stationary cycling

-50 min -50 min -50 min

Week 24 Yoga Strength training Stationary cycling

-50 min -50 min -50 min
Appendix A: Nutrition Knowledge and Self Efficacy Questionnaire

Name:___________________

Nutrition
Pre/Post-Assessment

Part A:

1. List the 3 macronutrients.

2. On scale of 1-5, 5 being the highest, how likely are you to pick a whole grain option?

1 2 3 4 5

3. Please indicate the types of whole grains consumed.

4. List an example of a non-meat protein source.

5. According to myplate, how much of your plate should be fruits and vegetables?

6. Which type of milk product are you mostly likely to choose?

a) Whole milk
b) 1%
c) Fat free
d) Milk alternative (almond, soy, etc)
e) 2%

7. In what stage are calorie needs the highest?

a) First trimester
b) Second trimester
c) Third trimester
d) Lactation

8. True or False: Folate is an important nutrient to receive during pregnancy.

9. Which one of these foods is appropriate when introducing solid foods to your infant?
a) Mashed banana
b) Whole grapes
c) Pizza
d) Spaghetti

Part B:
On a scale of 1-5 with 5 being the highest, how confident are you in your ability to purchase healthy foods while
grocery shopping?

1 2 3 4 5

How satisfied are you with the healthfulness of your current diet?
a) Very satisfied
b) Somewhat satisfied
c) Neither satisfied nor dissatisfied
d) Somewhat unsatisfied
e) Very unsatisfied

On a scale of 1-5, 5 being the highest, how confident do you feel that you are getting all of the necessary nutrients
for pregnancy?

1 2 3 4 5

How satisfied are you with your current nutrition knowledge?

a) Very satisfied
b) Somewhat satisfied
c) Neither satisfied nor dissatisfied
d) Somewhat unsatisfied
e) Very unsatisfied

On a scale of 1-5, 5 being the highest, how confident are you in your ability to read a nutrition food label?

1 2 3 4 5

On a scale of 1-5, 5 being the highest, how confident are you in your ability to understand and follow the MyPlate
guidelines?

1 2 3 4 5
Appendix B: Physical Activity Questionnaire

Fitness Pre-Assessment

Name: __________________________
Age: ________

1. How often do you exercise?

2. What kind of exercise do you currently do?

3. How long do you do these exercises for?

4. What kind of exercises did you do before you were pregnant?

5. Have you changed the types or duration of your exercise since becoming pregnant?

6. How would you categorize your current activity level?

a. None
b. Little (less than 2 hrs/week)
c. Moderate (2-3 hrs/week)
d. High (more than 3 hrs/week)

7. What keeps you from exercising?

a. Lack of motivation
b. No time
c. Money
d. Lack of knowledge
e. Other:

8. On a scale of 1-5, 5 being extremely safe, how safe do you think physical activity is during pregnancy?

1 2 3 4 5

9. On a scale of 1-5, 5 being extremely important, how important do you think physical activity is during
pregnancy?
 1 2 3 4 5

10. On a scale of 1-5, 5 being most likely, how likely are you to stick with an exercise schedule after
attending these fitness classes?

1 2 3 4 5

11. On a scale of 1-5, 5 being the highest, how would you rate your endurance?

1 2 3 4 5

12. On a scale of 1-5, 5 being very flexible, how would you rate your flexibility?

1 2 3 4 5

13. What is a challenge you think you may encounter during these fitness classes?

14. What is one skill you hope to learn from these classes?

Appendix C: Attendance Record (Education and Fitness)

Class Sign In
Class Offered: _______________
 Date:__________________________

Participant Name Participant Signature

Instructor Name: _______________________________

Instructor Signature: _____________________________

Appendix D: Sample Nutrition Education Lesson Plan

Lesson Plan: Introducing Solid Foods to Your Infant

Topic Week Instructor Date

 Intro to solid foods 21

Questions to discuss:
1. When do I know when my infant is ready for solid foods?
2. How do I start introducing solid foods to my infant?
3. What types of foods should I give/avoid?

Learning Goals/Objectives Assessments of Learning

Determine appropriate age to introduce specific Powerpoints and post assessment

foods to baby.

Recognize certain foods to avoid. Powerpoints and post assessment

How to prepare simple foods for the infant. Handouts and recipes from instructor

Resources to Aid Learning:

● Handouts from instructor
● Recipes
● Powerpoints

Topics to Cover:
● Discuss types of foods and what ages to receive.

Foods for Infant Age to Receive Tips

Exclusively Breastmilk or formula up to 6 months Consult with a lactation

consultant

single-grain cereals at 6 months Can mix w/ breastmilk

Pureed fruits/veggies at 6 months Use breastmilk, plastic spoon

Pureed protein sources (ex. at 6 months Use breastmilk, plastic spoon

chicken, tofu, beans)

Foods to avoid:
● Discuss which foods to avoid and why:
 -cow’s milk for 1st year of life → infants cannot digest yet
-nuts, shellfish, egg whites → potential allergens
-whole grapes, celery, raisins, sticky foods, hot dogs, popcorn, peanut butter → choking hazards
-honey → risk of botulism
-rare meat → risk of bacteria
-unpasteurized juice → risk of bacteria
-salt → harmful to infant’s kidneys
-sugary beverages/juices → excess sugar can lead to overweight/obesity and promote tooth
decay
-citrus during 1st year → high acidity

Determining Readiness
● Discuss certain signs to look for when infant may be ready to integrate solids into their diet:
-infant shows interest in food
-infant can hold head up and sit up without assistance

Closure/Reflection:
● Emphasize the main takeaway points:
-Look for signs your infant may be ready to transition to semi-solid foods (usually around 6
months of age).
-Start introducing new semi-solid foods into infant’s diet each week.
- Introduce single-ingredients foods first to identify any intolerances/allergies the infant may
have.
-Only feed the infant when he/she is hungry, and do not overfeed them or force them to finish their meal
as this can cause unhealthy relationships with food later on in life.

References:
1. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and
Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

2. Trust for America’s Health and the Robert Wood Johnson Foundation. The State of Obesity
website. https://stateofobesity.org/data/. Accessed October 11, 2018.

3. Josefson J. The Impact of Pregnancy Nutrition on Offspring Obesity. Journal of the Academy of
Nutrition and Dietetics. 2011; 111(1): 50-52. doi:10.1016/j.jada.2010.10.015.

4. Whitaker RC. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early
Pregnancy. American Academy of Pediatrics. 2004; 114(1): 29-36. doi: 10.1542/peds.114.1.e29.

5. Gaillard R, Felix JF, Duijts L, Jadoe VW. Childhood consequences of maternal obesity and
excessive weight gain during pregnancy. Nordic Federation of Societies of Obstetrics and
Gynecology. 2014; 93: 1085-1089. doi: 10.1111/aogs.12506.

6. Mazloomy-Mahmoodabad SS. Impact of Nutrition Education in Improving Dietary Pattern

During Pregnancy Based on Pender's Health Promotion Model: A Randomized Clinical Trial.
Iranian Journal of Nursing and Midwifery Research. 2018; 23(1): 18-25. doi:
10.4103/ijnmr.IJNMR_198_16.

7. Girard AW, Olude O. Nutrition Education and Counselling Provided during Pregnancy:Effects on
Maternal, Neonatal and Child Health Outcomes. The Society for Pediatric and Perinatal
Epidemiologic Research. 2012; 26(1): 191-204. doi: 10.1111/j.1365-3016.2012.01278.

8. Practice ACOO. Committee opinion #267: exercise during pregnancy and the postpartum period.
Obstetrics & Gynecology. 2002; 99(1): 171-173. doi:10.1016/s0029-7844(01)01749-5.

9. Hourly Wage for Dietitians in the United States. Salary.com. https://www1.salary.com/dietitian-

hourly-wages.html. Accessed November 13, 2018.

10. Office Supplies, Technology, Ink & Much More | Staples®. staples.com.
https://www.staples.com/. Accessed October 11, 2018

11. Wang TW, Apgar BS. Exercise During Pregnancy. American Family Physician.
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2018.