| 1. |
- Söderström, Emmie, 1990-
(författare)
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HealthyMoms - promoting healthier lifestyle and weight gain during pregnancy with special emphasis on migrant women
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Gestational weight gain (GWG), affects almost 50% of pregnant women and effective and scalable interventions are needed and should be inclusive for all irrespectively of origin. The overall aim of this thesis was to evaluate the HealthyMoms app targeting GWG as well as dietary and physical activity behaviors and how the app may be adapted to also reach women of migrant backgrounds. The first part evaluated the effectiveness of the HealthyMoms trial and the dietary assessment method used in it (Paper I-II). The second part aimed to explore how the HealthyMoms app could be adapted to reach Arabic- and Somali-speaking women (Paper III-IV). Methods: Paper I was a randomized controlled trial in healthy pregnant women (n=305). After baseline assessment (week 14), women were randomized to the intervention (n=152) or control group (n=153). The intervention group received standard care and the HealthyMoms app. The primary outcome was GWG between baseline and follow-up measurement (week 37). Secondary outcomes included body fatness (air displacement plethysmography), dietary habits (SHEI score), moderate-to-vigorous physical activity (accelerometry), glycemia and insulin resistance. Paper II: Nested validation study of RiksmatenFlex (dietary assessment method in HealthyMoms) in a subsample of the trial. Three days of dietary data (energy, foods groups, macronutrients and SHEI score) from RiksmatenFlex was compared to 24 h telephone dietary recalls (n=52). Total energy expenditure (TEE) was measured with the doubly labelled water method (n=24). Paper III: A qualitative exploration of healthcare professionals’ views on supporting healthy lifestyle behaviors in pregnant migrant women was performed through individual interviews over phone or in person with healthcare professionals working in maternity healthcare (n=14). An inductive thematic analysis was performed. Paper IV: Individual interviews with Arabic (n=10) and Somali women (n=9) exploring what support is needed for healthy lifestyle behaviors and how the HealthyMoms app could be adapted. Data was analyzed using content analysis (inductive latent approach). Results: Paper I: No statistically significant effect on GWG was observed, although data indicated that the effect of the HealthyMoms app differed according to pre-pregnancy BMI, where women with overweight and obesity in the intervention group had lower GWG compared to the control group in the imputed (–1.33 kg; 95% CI –2.92 to 0.26; P=.10) and completers-only analyses (–1.67 kg; 95% CI –3.26 to –0.09; P=.031). Participants in the intervention group further had higher SHEI score at follow-up compared to the control group (0.27; 95% CI 0.05-0.50; P=.017). No other effects for secondary outcomes were found. Paper II: Average energy intake from RiksmatenFlex (10015 [SD 2004] kJ) was similar to TEE (10252 [SD 1197] kJ) (P=.596). Mean differences between average intakes of unhealthy and healthy foods and average SHEI score between RiksmatenFlex and 24 h telephone dietary recalls were small, although Bland and Altman analyses showed wide limits of agreement for all variables. Moreover, correlations between dietary variables assessed with the two dietary methods were high (r=0.751-0.931; P<.001). Paper III: Healthcare professionals discussed challenges in their health promotion work including cultural and educational aspects as well as the need of increased awareness among pregnant migrant women and persons in the social context. Healthcare professionals further highlighted a lack of resources in the clinical practice and a need for increased cultural awareness in themselves to support healthy lifestyle behaviors. Providing the HealthyMoms app in Arabic and Somali with culturally adjusted information could be a helpful tool for women and for healthcare professionals in maternity healthcare. Paper IV: Arabic- and Somali-speaking women expressed a need of more knowledge about pregnancy and healthy lifestyle behaviors. The social context, and especially partners could support lifestyle behaviors. The social context could further be a source of misinformation which might negatively affect women’s diet or physical activity. Women had high trust in maternity healthcare but wanted more information related to lifestyle behaviors. A translated HealthyMoms app was seen as a helpful support for lifestyle behaviors, and it was reported that translation alone could be sufficient, however, audio- and video content was requested as well as inclusion of partners in the app. Conclusions: This thesis shows that the HealthyMoms app significantly improved dietary habits among pregnant women and has potential to reduce GWG in women with overweight and obesity. The dietary assessment method (RiksmatenFlex) showed acceptable agreement for average energy, macronutrients, key food groups and adherence to dietary guidelines, which strengthens the credibility of the obtained trial results and supports further use of the method. Finally, this thesis demonstrates the potential of the HealthyMoms app also for Arabic- and Somali-speaking women, i.e., two of the largest migrant groups in Sweden. It was requested that the app should include audio and video content, however, the need of other cultural adaptations needs further investigation.
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| 2. |
- Seiterö, Anna, 1982-
(författare)
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mHealth Targeting Physical Activity, Diet, Alcohol, and Smoking among Swedish High School Students : Processes and Outcomes of a Multiple Health Behavior Change Intervention (LIFE4YOUth)
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Effective health promotion and disease prevention strategies are required to achieve societies where preventable diseases are effectively prevented. Physical activity, diet, alcohol consumption, and tobacco use are all determinants for high-prevalent diseases such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. The cumulative risk of multiple health risk behaviors exceeds the combined risk of each individual behavior. Because health behaviors are formed during childhood and adolescence and occur in clusters that overall affect health, interventions targeting multiple health behaviors in these populations may have a lasting impact on public health. Schools are important for health promotion and disease prevention in children and adolescents. Nevertheless, the literature indicates that school-based interventions that involve school staff to address health-risk behaviors tend to be short-term projects due to barriers that impede long-term implementation. Mobile phones can provide resources for adolescents to promote their health, such as health applications and short text messages that do not rely on school personnel. However, more research is required to better understand whether stand-alone mobile phone-delivered interventions that target multiple health behaviors are a viable way to encourage health-promoting behaviors in adolescents.Aim: This thesis aims to gain knowledge about health behavior change among Swedish high school students, including the use and effects of an mHealth intervention (LIFE4YOUth) targeting four health behaviors (physical activity, diet, alcohol consumption, and cigarette smoking). The overall aim was addressed through four sub-studies, which specifically aimed to: identify and describe how high school students perceive health behavior change and how mobile phones are used in the process of change (Paper I), explore how high school students understand, interpret, and apply the content of LIFE4YOUth and describe consequences on psychological resources relevant to behavior change (Paper II), investigate explanations for engagement among high school students with access to LIFE4YOUth (Paper III), and estimate the two- and four-month effectiveness of LIFE4YOUth on individual health behaviors (physical activity, diet, alcohol consumption, and cigarette smoking) compared to a waiting list control condition (Paper IV).Intervention: The LIFE4YOUth intervention gave participants four-month access to weekly prompts for recording health behaviors and receiving feedback based on national guidelines, a four-module interactive dashboard with content structured around two main questions: why change and how to change health behaviors, and text message services for each targeted behavior.Methods: All studies were conducted between 2019 and 2023 and included approximately 800 students from high schools all over Sweden. Two studies had a qualitative approach, with data collected through focus groups (Paper I) and individual interviews with "think aloud" techniques (Paper II). Data were analyzed using thematic analysis (Paper I) and qualitative content analysis (Paper II). One study (paper III) had a mixed-methods design with data collected from participants in the intervention arm of the LIFE4YOUth trial. The analysis included statistical analyses, qualitative content analysis, and qualitative comparative analysis. Finally, a two-armed randomized controlled trial (1:1) with an intervention group and a waiting list control group was enrolled (Paper IV). Data was collected through web-based questionnaires at baseline and after two and four months. All primary outcomes were analyzed using regression models with inferences drawn from Bayesian analysis and null hypothesis testing.Results: The process of health behavior change was understood as a learning process facilitated by independence, an open approach, and self-acceptance while striving for social ideals such as togetherness with friends. Participants engaged with LIFE4YOUth to varied extent, which can be explained by varied interest in behavior change, experiences with the intervention, and circumstances in their social environment. Most participants responded to the weekly prompts in ≤ 2 out of 16 weeks, with 58% engaging with the intervention at least once. The dashboard content had the potential to provide participants with insights that facilitate health behavior change, but participants understood, interpreted, and applied the content in varied ways depending on whether they deliberately acknowledged their interpretation of concepts, took their prior knowledge into consideration to comprehend what was not explicitly outlined, and placed themselves in the center by accounting for their personal needs when interacting with the content.After two months, the intervention group participants had on average 50 minutes more of moderate to vigorous physical activity per week compared with the control group participants (95% CI = -0.19; 99.73, probability of effect = 97.4%, P=.05), and on average 0.32 more daily portions of fruits and vegetables (95% CI = 0.13; 0.53, probability of effect = 99.9%, P=.001). Furthermore, the probability of effect on weekly consumption of sugary drinks was 86% (IRR = 0.89, 95% CI = 0.73; 1.1, P=.29) and 94% on monthly frequency of heavy episodic drinking (IRR = 0.77, 95% CI = 0.55; 1.07, P=.14). The evidence for effect was weaker after four months. There was no marked evidence for an effect on weekly alcohol consumption or smoking cessation.Conclusion: The findings of this thesis indicate that the LIFE4YOUth intervention can raise Swedish high school students’ awareness of their health behaviors, encourage them to change their health-risk behaviors, and facilitate their process of adopting new behaviors. Nonetheless, the intervention’s potential may vary depending on high school students' interest in and cognitive processing of the intervention content. The strongest evidence for effect was on the weekly time spent in moderate to vigorous physical activity and the daily number of portions consumed of fruit and vegetables. These findings should encourage further research to gain more robust evidence on whether and how stand-alone mHealth multiple behavior change interventions are effective in promoting healthy behaviors among adolescents.
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| 3. |
- Alexandrou, Christina, 1981-
(författare)
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MINISTOP 2.0 : a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviors and prevent obesity in preschool-aged children
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundChildhood overweight and obesity is currently estimated to affect 39 million children under the age of five worldwide. After the COVID-19 pandemic, further increases have been observed in several countries including Sweden, where an increased incidence was observed in 3- and 4-year-old children, especially in disadvantaged areas. This development emphasizes the urgent need for population-based childhood obesity prevention interventions, and Swedish primary child health care provides an ideal setting for primary preventive efforts during the preschool years. However, thus far, previous child health care-based obesity prevention interventions have demonstrated limited effectiveness. As previous interventions also have been face-to-face delivered and thus resource-demanding; new, and scalable ways of delivering interventions also need to be evaluated. Mobile health or mHealth refers to the use of mobile devices for medical and public health practice and provides opportunity for development and dissemination of digital interventions for various purposes and populations at scale. This thesis reports the results of the MINISTOP 2.0 project, which covers the development and evaluation of the MINISTOP 2.0 digital intervention, from adaptation and translation of the intervention to Somali, Arabic and English (Paper I), to evaluation of real-world effectiveness within the Swedish primary child health care setting (Paper II) followed by exploration of user experiences and implementation aspects (Paper III) and a cost-consequence analysis of the intervention costs (Paper IV). AimThe overall aim of this thesis was to evaluate whether a 6-month parent-oriented mHealth intervention (MINISTOP 2.0 app), embedded in the routine services of Swedish primary child health care, can be used to improve diet and physical activity behaviors, and decrease the prevalence of over-weight and obesity in 2.5-to-3-year-old children. MethodsThe MINISTOP 2.0 project utilized a hybrid type 1 effectiveness-implementation study design to enable simultaneous evaluation and exploration of intervention effectiveness, user experiences and implementation aspects. Paper I: A qualitative exploration of user requirements in an app-based parental support intervention was conducted through three focus group interviews with Somali- (n = 5), Arabic- (n = 4), and Swedish-speaking parents (n = 6), and individual interviews with child health care nurses (n = 15). Data was analyzed using thematic analysis. Paper II: A two-arm parallel randomized controlled trial was conducted at 19 child health care centers located in six Swedish regions. Participating parents (n = 552) were invited during their routine visit at 2.5/3-years at their primary child health care center. All baseline and follow-up procedures were conducted by the nurses. Parents that were randomized to the control group received standard care, while the intervention group received access to the MINISTOP 2.0 app for six months, alongside standard care. Prior to randomization, nurses measured the child’s height and weight for assessment of BMI, and parents answered a questionnaire about their child’s intake of fruit and vegetables, sweet and savory treats, and sweet drinks; time spent in moderate-to-vigorous physical activity (MVPA) and screen time; and parental self-efficacy (PSE) for promoting healthy diet, physical activity, and screen time behaviors. These baseline procedures were then repeated at a 6-month follow-up visit to the child health care center. Paper III: A qualitative exploration of user experiences, acceptability, and feasibility of the MINISTOP 2.0 intervention was conducted through individual interviews with parents (n = 24) with diverse backgrounds, and with child health care nurses (n = 15). Data was analyzed using content analysis. Paper IV: Data on all costs related to the MINISTOP 2.0 intervention, including costs for app and interface upkeep as well as salary costs for introduction and dissemination of the app by nurses, was collected retrospectively. A cost-consequence analysis was then performed to estimate the costs of the intervention. ResultsPaper I: Parents expressed several challenges related to promoting healthy eating behaviors, such as worrying about their child not eating enough, and difficulties balancing different food cultures. There were also requests for the app content to be accessible through alternative modes of delivery (e.g., audio/video) for parents with low literacy. Nurses underlined the importance of supporting parents early with health behavior interventions, and the value of a shared digital platform, available in several languages, to facilitate communication with parents. Paper II: Seventy-nine percent of the participating parents (n = 552) were mothers and 62% had a university degree. Among the children, 24% had two foreign-born parents. Children in the intervention group had lower in-takes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) com-pared to the control group at follow-up. Parents in the intervention group also reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet behaviors (0.34; p = 0.008) and PSE for promoting healthy physical activity behaviors (0.31; p = 0.009) compared to the control group. For children’s MVPA or BMI z-score, no statistically significant effect was observed between groups. Finally, parents also reported high satisfaction with the app, and 54% reported using the app once a week or more. Paper III: Findings indicated that the app was well accepted and appreciated, as it increased knowledge and awareness around current health behaviors. Furthermore, evidence-based information available in one place and from a trusted source, was highly valued, especially when living in a country with a different culture than your own. The app was also acknowledged as a feasible support tool and a suitable complement to the standard care offered during visits. Finally, due to the accessibility in different languages and the possibility of disseminating the app at scale, both nurses and parents described the app as an appropriate tool for reaching larger populations of parents as well as parents in need of additional support. Paper IV: The total cost for the MINISTOP 2.0 intervention was 437 439 SEK based on the 277 families in the intervention group. The cost for child health care nurses introducing and registering families for the app represented only 9% of the total cost per family, which was considerably lower in comparison to other similar childhood obesity prevention interventions. Also, notably, for upscaling, sharing running costs for the user interface for larger populations of children, would result in much lower total costs per family. ConclusionsOverall, qualitative findings for adapting the intervention highlighted the need for early access to information, as well as the importance of adapting interventions to also be accessible for parents with migrant background and parents with lower literacy. When disseminated through primary child health care, the MINISTOP 2.0 intervention resulted in statistically significant reduced intakes of sweet and savory treats, sweet drinks, and screen time in children (primary outcomes) as well as increased PSE for promoting healthy diet and activity behaviors (secondary outcome). The app was well accepted and perceived as a feasible support tool for parents. Furthermore, accessibility in different languages was also appreciated. Finally, the relatively low salary costs in comparison to face-to-face interventions suggest that the MINISTOP 2.0 app and caregiver interface may be an affordable preventive effort for early promotion of healthy lifestyle behaviors in children when scaled up on a population level. Altogether, the results from the papers in this thesis support the large-scale implementation of the MINISTOP 2.0 app within the Swedish primary child health care setting for promotion of healthy lifestyle behaviours in 2.5-to-3-year-old children.
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| 4. |
- Lappi, Veli-Matti, et al.
(författare)
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A Comparison of the Nutritional Qualities of Supermarket's Own and Regular Brands of Bread in Sweden
- 2020
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Ingår i: Nutrients. - : MDPI. - 2072-6643. ; 12:4
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Tidskriftsartikel (refereegranskat)abstract
- Processed food is associated with unhealthy qualities such as higher content of harmful fats, sugars and salt. The aim of our study was to compare the nutritional qualities of supermarket's own brands and regular brands of bread sold in Sweden. Additionally, we compared the nutritional qualities of gluten-free and gluten-containing bread. We collected information from the labels of 332 bread products available in the largest grocery store chains. The Australian Health Star Rating (HSR) system was used to quantify the nutritional quality of each bread product. We compared all supermarket's own brand products to regular brand products, and gluten-free to gluten-containing bread. The mean HSR for the supermarket's own brands was lower than the regular brands (3.6 vs. 3.7; p = 0.046). For the regular brand products, the fibre, sugar and total fat content were greater (p < 0.001, p = 0.002 and p = 0.021, respectively), while less protein (p = 0.009) compared to regular bread products. Gluten-free bread had a lower HSR than gluten-containing bread (mean 3.5 vs. 3.8, respectively; p < 0.001). The regular brand products were slightly healthier than the supermarket's own brands, primarily as a result of a higher fibre content. Gluten-free bread products were slightly unhealthier due to a lower protein content.
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| 5. |
- Löf, Marie, 1971-
(författare)
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Studies on energy metabolism and body composition of healthy women before, during and after pregnancy
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Current recommendations propose that an entire pregnancy requires an additional amount of energy from the diet equivalent to 335 000 kJ. This figure is mainly based on increases in the basal metabolic rate (BMR) and retention of total body fat (TBF). The BMR response to pregnancy varies considerably among women, but the factors responsible for this variability are unknown. TBF can be calculated from total body water (TBW) and the hydration factor (HF), using the so-called two-component model. However, the validity of this model during pregnancy has been questioned. Furthermore, current recommendations propose that energy needs during pregnancy may be partly offset by reductions in physical activity, but this statement is supported by little experimental evidence. The aims of this thesis were: to evaluate if the physical activity level (PAL) can be estimated by means of heart rate recording, accelerometry, and a questionnaire in women planning pregnancy; to assess the effect of pregnancy on energy expenditure due to physical activity, on activity pattern and on the biological variability of HF; to evaluate the use of bioimpedance spectroscopy (BIS) for assessing TBW during pregnancy; and to identifY factors explaining the variability of the BMR response to pregnancy.Healthy women were studied before pregnancy (n=38), and in gestational weeks 8, 14, 20, 32, 35 and 2 weeks post partum (n=23). Total energy expenditure (TEE), BMR, TEE/BMR, activity pattern, body composition, circulatory variables and serum levels of thyroid hormones and insulin growth factor-I (IGF-1) were measured. Foetal weight in gestational week 31 and infant birth weight were assessed.All estimates of PAL were imprecise and too low in women planning pregnancy. There was little change in TEE/BMR in gestational week 14, but it was significantly reduced in gestational week 32. However, activity pattern was largely unaffected by pregnancy. The biological variability of HF was 2%, 3% and 1.7% or less of average HF before pregnancy and in gestational weeks 14 and 32, respectively. BIS underestimated TBW during pregnancy. In gestational week 14, the increase in BMR correlated significantly with the increase in body weight and with TBF (%)before pregnancy. Together these variables explained about 40% of the variability in the BMR response. In gestational week 32, the increase in BMR correlated significantly with changes in body weight, TBF, fat-free mass, IGF-I, cardiac output and free triiodothyronine. At this stage of gestation the increase in body weight in combination with foetal weight or with the increased levels of IGF-I in serum explained about 60% of the variability of the increased BMR.In conclusion: I) Heart rate recording, accelerometry and the questionnaire produced inappropriate PAL estimates. 2) In women maintaining their pre-pregnant activity pattern the increase in BMR represents the major component of the increased energy expenditure during pregnancy. 3) The two-component model for assessing TBF is appropriate in late gestation, while its precision may be impaired in early pregnancy. 4) BIS in its present form is not appropriate for assessing TBW during pregnancy. 5) Nutritional factors are important regarding the variability in the BMR response to pregnancy.
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| 6. |
- Mottas, Antoine, et al.
(författare)
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Measuring the Healthiness of Ready-to-Eat Child-Targeted Cereals : Evaluation of the FoodSwitch Platform in Sweden
- 2021
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Ingår i: JMIR mhealth and uhealth. - : JMIR Publications. - 2291-5222. ; 9:7
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Tidskriftsartikel (refereegranskat)abstract
- Background: Childhood obesity is a major public health issue. The increase in the consumption of foods with poor nutritional value, such as processed foods, contributes to this. Breakfast cereals are often advertised as a healthy way to start the day, but the healthiness of these products varies greatly. Objective: Our main objective was to gather information about the nutritional characteristics of ready-to-eat breakfast cereals in Sweden and to investigate the healthiness of products targeted at children compared to other cereals by use of the FoodSwitch platform. A secondary objective was to evaluate the alignment between the Keyhole symbol and the Health Star Rating. Methods: The FoodSwitch app is a mobile health (mHealth) tool used to present nutrition data and healthier alternative products to consumers. Ready-to-eat breakfast cereals from the largest Swedish grocery retailers were collected using the FoodSwitch platform. Products were defined as targeting children if they presented features addressing children on the package. Results: Overall, information on 261 ready-to-eat cereals was examined. Of this total, 8% (n=21) were targeted at children. Child-targeted cereals were higher in sugar (22.3 g/100 g vs 12.8 g/100 g, P<.001) and lower in fiber (6.2 g/100 g vs 9.8 g/100 g, P<.001) and protein (8.1 g/100 g vs 10.5 g/100 g, P<.001). Total fat (3 g/100 g vs 10.5 g/100 g, P<.001) and saturated fat (0.8 g/100 g vs 2.6 g/100 g, P<.001) were also lower. No difference was found in salt content (P=.61). Fewer child-targeted breakfast cereals displayed an on-pack Keyhole label (n=1, 5% vs n=53, 22%; P=.06), and the mean Health Star Rating value was 3.5 for child-targeted cereals compared to others (mean 3.8, P=.07). A correlation was found between the Keyhole symbol and the Health Star Rating. Conclusions: Ready-to-eat breakfast cereals targeted at children were less healthy in terms of sugar and fiber content compared to products not targeted at children. There is a need to improve the nutritional quality of child-targeted cereals.
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