No Improvements in Postnatal Dietary Outcomes Were Observed in a Two-Arm, Randomized, Controlled, Comparative Impact Trial among Rural, Southern, African-American Women

Published:February 01, 2018DOI:



      Suboptimal diet quality, prevalent among postpartum women, is troubling for mothers and their children because positive relationships between maternal and child diet quality exist.


      The primary objective was to determine whether postnatal diet quality scores of participants in the two treatment arms differed or changed over time.


      Delta Healthy Sprouts was a two-arm, randomized, controlled, comparative impact trial.

      Participants and setting

      Pregnant women at least 18 years of age, less than 19 weeks pregnant, and residing in three Mississippi counties were recruited between March 2013 and December 2014. Postnatal data was collected from 54 participants between September 2013 and May 2016. The postnatal attrition rates were 17% and 13% for the control and experimental arms.


      The control arm received the Parents as Teachers curriculum, and the experimental arm received a nutrition- and physical activity-enhanced Parents as Teachers curriculum.

      Main outcome measures

      Multiple-pass 24-hour dietary recalls were collected from participants at the postnatal month 1, 4, 6, 8, and 12 visits. Healthy Eating Index-2010 was used to calculate diet quality.

      Statistical analysis performed

      Linear mixed models were used to test for treatment, time, and treatment by time (interaction) effects on postnatal dietary outcomes.


      Control arm mean (95% confidence limits) total Healthy Eating Index-2010 scores were 36.8 (range=32.5 to 41.1), 36.5 (range=31.9 to 41.1), 40.2 (range=35.7 to 44.8), 39.3 (range=34.7 to 43.9), and 36.4 (range=31.8 to 41.0) at postnatal months 1, 4, 6, 8, and 12, respectively. Corresponding experimental arm scores were 42.3 (range=37.5 to 47.0), 41.6 (range=36.3 to 46.9), 40.2 (range=34.8 to 45.7), 45.8 (range=40.5 to 51.1), and 37.6 (range=32.6 to 42.7), respectively. Experimental scores were significantly higher than control scores across time. No other effects were significant.


      Neither the standard Parents as Teachers curriculum nor the enhanced Parents as Teachers curriculum was effective at improving the poor diet quality of this cohort of rural, Southern, African-American women during the 12 months following the birth of their infant.


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        • Durham H.A.
        • Lovelady C.A.
        • Brouwer R.J.
        • Krause K.M.
        • Ostbye T.
        Comparison of dietary intake of overweight postpartum mothers practicing breastfeeding or formula feeding.
        J Am Diet Assoc. 2011; 111: 67-74
        • Fowles E.R.
        • Walker L.O.
        Correlates of dietary quality and weight retention in postpartum women.
        J Community Health Nurs. 2006; 23: 183-197
        • George G.C.
        • Milani T.J.
        • Hanss-Nuss H.
        • Freeland-Graves J.H.
        Compliance with dietary guidelines and relationship to psychosocial factors in low-income women in late postpartum.
        J Am Diet Assoc. 2005; 105: 916-926
        • Hiza H.A.
        • Casavale K.O.
        • Guenther P.M.
        • Davis C.A.
        Diet quality of Americans differs by age, sex, race/ethnicity, income, and education level.
        J Acad Nutr Diet. 2013; 113: 297-306
        • Laster L.E.
        • Lovelady C.A.
        • West D.G.
        • et al.
        Diet quality of overweight and obese mothers and their preschool children.
        J Acad Nutr Diet. 2013; 113: 1476-1483
        • Spence A.C.
        • Campbell K.J.
        • Crawford D.A.
        • McNaughton S.A.
        • Hesketh K.D.
        Mediators of improved child diet quality following a health promotion intervention: The Melbourne InFANT Program.
        Int J Behav Nutr Phys Act. 2014; 11: 137
        • van der Pligt P.
        • Willcox J.
        • Hesketh K.D.
        • et al.
        Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth.
        Obes Rev. 2013; 14: 792-805
        • Johnston B.D.
        • Huebner C.E.
        • Anderson M.L.
        • Tyll L.T.
        • Thompson R.S.
        Healthy steps in an integrated delivery system: child and parent outcomes at 30 months.
        Arch Pediatr Adolesc Med. 2006; 160: 793-800
        • Olds D.L.
        • Henderson Jr., C.R.
        • Tatelbaum R.
        • Chamberlin R.
        Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation.
        Am J Public Health. 1988; 78: 1436-1445
        • Olds D.L.
        • Kitzman H.
        • Hanks C.
        • et al.
        Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial.
        Pediatrics. 2007; 120: e832-e845
        • Olds D.L.
        • Robinson J.
        • Pettitt L.
        • et al.
        Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial.
        Pediatrics. 2004; 114: 1560-1568
        • Thomson J.L.
        • Tussing-Humphreys L.M.
        • Goodman M.H.
        Delta Healthy Sprouts: A randomized comparative effectiveness trial to promote maternal weight control and reduce childhood obesity in the Mississippi Delta.
        Contemp Clin Trials. 2014; 38: 82-91
        • Thomson J.L.
        • Tussing-Humphreys L.M.
        • Goodman M.H.
        • Olender S.E.
        Gestational weight gain: results from the Delta Healthy Sprouts comparative impact trial.
        J Pregnancy. 2016; : 1-12
        • Thomson J.L.
        • Tussing-Humphreys L.M.
        • Goodman M.H.
        • Olender S.E.
        Physical activity changes during pregnancy in a comparative impact trial.
        Am J Health Behav. 2016; 40: 685-696
        • Thomson J.L.
        • Tussing-Humphreys L.M.
        • Goodman M.H.
        • Olender S.E.
        Low rate of initiation and short duration of breastfeeding in a maternal and infant home visiting project targeting rural, Southern, African American women.
        Int Breastfeed J. 2017; 12: 1-11
        • Tussing-Humphreys L.M.
        • Thomson J.L.
        • Goodman M.H.
        • Olender S.
        Maternal diet quality and nutrient intake in the gestational period: results from the Delta Healthy Sprouts comparative impact trial.
        Matern Health Neonatol Perinatol. 2016; 2: 8
      1. SAS [computer program]. Version 9.4 (TS1M2). Cary, NC: SAS Institute Inc; 2013.

      2. Parents as Teachers National Center Inc. Parents as Teachers. Accessed April 12, 2017.

        • Bandura A.
        Human agency in social cognitive theory.
        Am Psychol. 1989; 44: 1175-1184
        • Prochaska J.O.
        • Velicer W.F.
        The transtheoretical model of health behavior change.
        Am J Health Promot. 1997; 12: 38-48
        • Knowler W.C.
        • Barrett-Connor E.
        • Fowler S.E.
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Campbell K.J.
        • Lioret S.
        • McNaughton S.A.
        • et al.
        A parent-focused intervention to reduce infant obesity risk behaviors: A randomized trial.
        Pediatrics. 2013; 131: 652-660
        • Nowak A.J.
        • Casamassimo P.S.
        Using anticipatory guidance to provide early dental intervention.
        J Am Dent Assoc. 1995; 126: 1156-1163
        • Mullis F.
        Active parenting: An evaluation of two Adlerian parent education programs.
        J Individ Psychol. 1999; 55: 359-364
        • Andrews J.O.
        • Felton G.
        • Wewers M.E.
        • Heath J.
        Use of community health workers in research with ethnic minority women.
        J Nurs Scholarsh. 2004; 336: 358-365
      3. NDSR [computer program]. Version 2014. Minneapolis, MN: University of Minnesota Nutrition Coordinating Center; 2014.

        • Guenther P.M.
        • Casavale K.O.
        • Reedy J.
        • et al.
        Update of the Healthy Eating Index: HEI-2010.
        J Acad Nutr Diet. 2013; 113: 569-580
        • Sallis J.F.
        • Grossman R.M.
        • Pinski R.B.
        • Patterson T.L.
        • Nader P.R.
        The development of scales to measure social support for diet and exercise behaviors.
        Prev Med. 1987; 16: 825-836
        • Sallis J.F.
        • Pinski R.B.
        • Grossman R.M.
        • Patterson T.L.
        • Nader P.R.
        The development of self-efficacy scales for health-related diet and exercise behaviors.
        Health Educ Res. 1988; 3: 283-292
        • Tippett K.S.
        • Cleveland L.E.
        Results from USDA’s 1994-96 Diet and Health Knowledge Survey.
        US Department of Agriculture, Nationwide Food Survey Report No. 96-4, 2001
      4. SnapSurveys [computer program]. Version 11. Portsmouth, NH: Snap Surveys Ltd; 2013.

        • Vos M.B.
        • Kimmons J.E.
        • Gillespie C.
        • Welsh J.
        • Blanck H.M.
        Dietary fructose consumption among US children and adults: the Third National Health and Nutrition Examination Survey.
        Medscape J Med. 2008; 10: 160
        • Drenowatz C.
        • Jakicic J.M.
        • Blair S.N.
        • Hand G.A.
        Differences in correlates of energy balance in normal weight, overweight and obese adults.
        Obes Res Clin Pract. 2015; 9: 592-602
        • Pate R.R.
        • Taverno Ross S.E.
        • Liese A.D.
        • Dowda M.
        Associations among physical activity, diet quality, and weight status in US adults.
        Med Sci Sports Exerc. 2015; 47: 743-750
        • Sijtsma F.P.
        • Meyer K.A.
        • Steffen L.M.
        • et al.
        Longitudinal trends in diet and effects of sex, race, and education on dietary quality score change: the Coronary Artery Risk Development in Young Adults study.
        Am J Clin Nutr. 2012; 95: 580-586
        • Nunnally J.C.
        Psychometric Theory.
        2nd ed. McGraw-Hill, New York, NY1978
        • Rehm C.D.
        • Monsivais P.
        • Drewnowski A.
        Relationship between diet cost and Healthy Eating Index 2010 scores among adults in the United States 2007-2010.
        Prev Med. 2015; 73: 70-75
        • Byrd-Bredbenner C.
        • Abbot J.M.
        • Cussler E.
        Relationship of social cognitive theory concepts to mothers’ dietary intake and BMI.
        Matern Child Nutr. 2011; 7: 241-252
        • Falciglia G.
        • Piazza J.
        • Ritcher E.
        • Reinerman C.
        • Lee S.Y.
        Nutrition education for postpartum women: A pilot study.
        J Prim Care Community Health. 2014; 5: 275-278
        • Huseinovic E.
        • Winkvist A.
        • Bertz F.
        • Brekke H.K.
        Changes in food choice during a successful weight loss trial in overweight and obese postpartum women.
        Obesity (Silver Spring). 2014; 22: 2517-2523
        • Wiltheiss G.A.
        • Lovelady C.A.
        • West D.G.
        • Brouwer R.J.
        • Krause K.M.
        • Ostbye T.
        Diet quality and weight change among overweight and obese postpartum women enrolled in a behavioral intervention program.
        J Acad Nutr Diet. 2013; 113: 54-62
      5. US Department of Agriculture. Accessed March 8, 2014.

        • Landry A.S.
        • Thomson J.L.
        • Huye H.F.
        • Yadrick K.
        • Connell C.L.
        Mississippi Communities for Healthy Living.
        Health Educ Behav. 2016; 44: 316-325
        • Aljuraiban G.S.
        • Chan Q.
        • Oude Griep L.M.
        • et al.
        The impact of eating frequency and time of intake on nutrient quality and body mass index: The INTERMAP Study, a population-based study.
        J Acad Nutr Diet. 2015; 115: 528-536
        • US Department of Health and Human Services and US Department of Agriculture
        2015-2020 Dietary Guidelines for Americans.
        8th ed. US Government Printing Office, Washington, DC2015
        • Bhupathiraju S.N.
        • Wedick N.M.
        • Pan A.
        • et al.
        Quantity and variety in fruit and vegetable intake and risk of coronary heart disease.
        Am J Clin Nutr. 2013; 98: 1514-1523
        • Condon E.
        • Drilea S.
        • Jowers K.
        • et al.
        Diet Quality of Americans by SNAP Participation Status: Data from the National Health and Nutrition Examination Survey, 2007-2010.
        United States Department of Agriculture, Food and Nutrition Service, 2015
        • Andreyeva T.
        • Tripp A.S.
        • Schwartz M.B.
        Dietary quality of Americans by Supplemental Nutrition Assistance Program participation status: A systematic review.
        Am J Prev Med. 2015; 49: 594-604
      6. Bell J, Mora G, Hagan E, Rubin V, Karpyn A. Access to healthy food and why it matters: A review of the research. PolicyLink and the Food Trust; 2013. Accessed October 21, 2017.

        • Larson N.I.
        • Story M.T.
        • Nelson M.C.
        Neighborhood environments: Disparities in access to healthy foods in the U.S.
        Am J Prev Med. 2009; 36: 74-81
      7. Ver Ploeg M, Mancino L, Todd JE, Clay DM, Scharadin B. Where do Americans usually shop for food and how do they travel to get there? Initial findings from the National Household Food Acquisition and Purchase Survey. US Department of Agriculture, Economic Research Service; 2015. Accessed October 21, 2017.

        • Darmon N.
        • Drewnowski A.
        Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: A systematic review and analysis.
        Nutr Rev. 2015; 73: 643-660
        • Hilmers A.
        • Hilmers D.C.
        • Dave J.
        Neighborhood disparities in access to healthy foods and their effects on environmental justice.
        Am J Public Health. 2012; 102: 1644-1654
        • Judd S.E.
        • Letter A.J.
        • Shikany J.M.
        • Roth D.L.
        • Newby P.K.
        Dietary patterns derived using exploratory and confirmatory factor analysis are stable and generalizable across race, region, and gender subgroups in the REGARDS Study.
        Front Nutr. 2014; 1: 29
        • Orcholski L.
        • Luke A.
        • Plange-Rhule J.
        • et al.
        Underreporting of dietary energy intake in five populations of African diaspora.
        Br J Nutr. 2015; 113: 464-472


      J. L. Thomson is a research epidemiologist, US Department of Agriculture, Agricultural Research Service, Delta Human Nutrition Research Program, Stoneville, Mississippi.


      M. H. Goodman is an epidemiologist, US Department of Agriculture, Agricultural Research Service, Delta Human Nutrition Research Program, Stoneville, Mississippi.


      L. M. Tussing-Humphreys is an assistant professor of medicine, Department of Medicine and Cancer Center, University of Illinois at Chicago, Chicago, Illinois.


      A. S. Landry is an assistant professor of nutrition, Department of Family and Consumer Sciences, University of Central Arkansas, Conway.