The Deep South has the highest rates of obesity, diabetes, and hypertension in the nation, with marked disparities by race, socioeconomic status, and rurality. The mission of the Forge AHEAD Center is to improve health outcomes and reduce the burden of cardiometabolic diseases across the Deep South, with a particular focus on the prevention and treatment of these chronic diseases. Forge AHEAD is unified thematically by its application of a precision public health approach across the care continuum, defined as delivering the right intervention to the right population at the right time. This approach acknowledges the importance of context and individual beliefs and preferences, as well as the need for multi-level and multi-domain interventions to achieve health improvements. The Center brings together an interdisciplinary team of investigators from 4 institutions in 3 contiguous states in the region, as well as non-academic partners to extend cardiometabolic research into real-world community and clinical settings. Given the high prevalence of cardiometabolic diseases in the Deep South and the strong research base of the partnering institutions, the Forge AHEAD Center is ideally situated to inform research, clinical care, and policy to improve health outcomes in a region of substantial need.

BACKGROUND:Weight loss maintenance (WLM) remains a limitation of behavioral obesity interventions, as long-term adherence is burdensome and diminishes over time. Simplified recommendations and/or alternative delivery methods that target evidence-based WLM strategies may reduce burden to improve long-term outcomes. METHODS:This protocol describes a multiphase optimization strategy (MOST) trial using a 2x2x2x2 factorial design to optimize a 12-month extended care program for weight loss maintenance. Adults with obesity who achieve at least 5% weight loss during an initial 4-month behavioral weight loss program are randomized to receive a core maintenance program plus zero to four "minimally disruptive" intervention components: reduced food variety, home-based resistance training, buddy training and support, and acceptance and commitment therapy workshops. RESULTS:The primary outcome is weight loss maintenance at 12 months following randomization. Secondary outcomes include treatment adherence, treatment burden, behavioral maintenance constructs, and hypothesized mediators and moderators of intervention effects. DISCUSSION:This study explores unconventional but evidence-based treatment strategies for WLM and applies a 'minimally disruptive medicine' paradigm to behavioral maintenance. These findings have the potential to inform best practices for the provision of WLM interventions, improve long-term outcomes for individuals accessing weight management services, and strengthen the overall public health impact of available interventions for disease prevention and management. TRIAL REGISTRATION:NCT, NCT06785064. Registered [01/15/2025], https://clinicaltrials.gov/study/NCT06785064?term=NCT06785064&rank=1.

BACKGROUND:Postpartum weight retention (PPWR) is common and associated with poor health outcomes. Traditional weight management approaches have limited success postpartum. Due to infant-related sleep disruptions, late-night eating may be more common postpartum and contribute to PPWR. Chrononutrition interventions, which align energy intake with circadian rhythms in metabolism, demonstrate promise for weight loss in nonpostpartum populations and offer a novel approach to preventing PPWR. However, no studies have explored whether chrononutrition approaches may be acceptable postpartum, which is needed to inform which approaches may warrant subsequent testing. OBJECTIVE:To characterize perceived determinants of eating timing and understand the feasibility of following various chrononutrition approaches among postpartum mothers. DESIGN:A qualitative descriptive study using semistructured interviews to query participants about the following chrononutrition approaches, which they also ranked from most to least preferred: bedtime stopping rule (no energy intake within a certain number of hours of bedtime); king's breakfast, pauper's dinner (distributing kilocalories so intake is highest at breakfast and lowest at dinner), and time-restricted eating (shortening the daily eating window to ≤10 hours). PARTICIPANTS/SETTING:Mothers (N = 10) within 6 months postdelivery recruited from the University of Alabama at Birmingham Hospital and interviewed between August and December 2023. ANALYSIS:Interviews were coded through an iterative process using an exhaustive approach. RESULTS:Themes influencing eating habits included infant schedule and availability of childcare/home assistance. Barriers to chrononutrition approaches included the importance of the evening family meal and enjoying relaxing and eating after children went to bed. Participants most preferred the bedtime stopping rule and were willing to stop eating a median of 2 hours before bedtime. CONCLUSIONS:This study provides novel insights into mothers' perceptions of implementing various chrononutrition approaches, highlighting the importance of external barriers (eg, partner work schedule). Findings can inform the development of novel chrononutrition interventions to manage PPWR.

Research shows that dietary interventions improve biomarkers of health span and aging. This paper describes the implementation and data collection methods for 4 dietary interventions and a control condition comprising the 5 arms of the Dietary Approaches to Longevity and Health (DiAL Health) Pilot study. DiAL Health is a 24-wk, randomized controlled pilot trial comparing the feasibility and preliminary efficacy of traditional and adaptive approaches to calorie restriction (CR) and time-restricted eating (TRE) on biomarkers of biological aging and health span in young, healthy adults [age: 25–49 y, body mass index (BMI): 22.0–29.9 kg/m2]. To our knowledge, this is one of the first studies to examine the effects of both CR and TRE against a usual diet and will generate preliminary data to inform a larger, longer-term comparative trial. The 2 CR arms of DiAL Health target 25% CR, whereas the 2 TRE arms promote ad libitum food intake within an 8-h daily window. Traditional CR and TRE arms will receive established interventions. The corresponding adaptive arms will receive Just-in-Time Adaptive Interventions that leverage mobile health technologies to adjust behavior and facilitate adherence with real-time or near-real-time feedback and support. Using a validated mathematical model, weight loss nomograms with measurements from internet-connected smart scales will be used to monitor dietary adherence in the adaptive CR arm. Feedograms with eating events populated by continuous glucose monitoring (CGM), the Remote Food Photography Method/SmartIntake app, and manual entry by counselors and participants will be used to monitor meal timing adherence in the adaptive TRE arm. Integration of CGM will support passive, automated detection of meal timing and eating behavior, potentially reducing reliance on self-reported measures. Findings from the DiAL Health Pilot study will inform the design and implementation of a future 5-y clinical trial evaluating personalized dietary strategies to promote longevity and improve health span.This trial was registered at clinicaltrials.gov as NCT05549362.

Background Calorie restriction (CR) and time-restricted eating (TRE) consistently improve biomarkers of aging and health span, yet long-term adherence to these dietary strategies remains difficult. Technology-enabled approaches, including just-in-time adaptive interventions (JITAIs), may facilitate greater engagement by delivering personalized support in response to an individual’s real-time behavior and circumstances. Objectives The Dietary Approaches to Longevity and Health (DiAL Health) pilot trial is designed to evaluate the feasibility, acceptability, and preliminary efficacy of adaptive (JITAI-supported) compared with traditional implementations of CR and TRE and to identify outcome measures suitable for larger, long-term intervention studies. Methods This 24-wk, parallel-arm, randomized controlled pilot trial will enroll 90 healthy adults aged 22 to 45 y with a BMI of 22.0 to 29.9 kg/m2 into 1 of 5 groups: nonintervention control, traditional or adaptive TRE with an 8-h eating window, and traditional or adaptive CR targeting a 25% reduction in energy intake. Traditional interventions will emphasize in-person counseling, whereas adaptive interventions will be supported by mobile health (mHealth) technology and incorporate remote monitoring via digital tools and JITAI-based feedback to quantify eating behaviors in real time and deliver tailored adherence prompts. Results Primary feasibility outcomes include adherence, retention, and participant satisfaction. Secondary outcomes to assess preliminary clinical efficacy include Klemera–Doubal as a composite measure of biological age and the metabolic syndrome score as a marker of health span. Additional measures including patient-reported outcomes and hallmarks of aging will be collected as exploratory outcomes. Effect sizes will be estimated to guide the selection of primary end points for future large-scale trials. Conclusions The DiAL Health pilot trial will provide essential data on the comparative feasibility and potential efficacy of adaptive with those of traditional dietary strategies, informing the development of scalable interventions aimed at improving health span and delaying biological aging.This trial was registered at clinicaltrials.gov as NCT05549362.

Body changes including weight gain and visceral adiposity are prevalent among women living with HIV and may pose risks for weight stigma-negative attitudes, beliefs, and judgments about a person related to their body size. We undertook a qualitative investigation to describe experiences of weight stigma and to compare and contrast those experiences among women living with and living without HIV. Participants were recruited from Women's Interagency HIV Study sites in Jackson, MS; Birmingham, AL; and Atlanta GA and invited to participate in an individual phone interview. Interviews were transcribed, coded by two members of the research team, and analyzed using deductive and inductive thematic analysis. Twenty-eight women completed interviews of whom 19 (68 %) were HIV+; 26 (95 %) were Black; with a range of body sizes approximated by BMI (range: 19-40+). Women described community weight stigma as it related to gender, race, HIV status, and age. Enacted weight stigma was pervasive, came from multiple sources, and related to being perceived as too thin or too big. Anticipated and internalized weight stigma were concerns described by women with larger bodies, but not smaller bodies. Women living with HIV expressed worries about abdominal fat accumulation revealing their HIV status. Overall, weight stigma was a common experience among women regardless of HIV status. Women living with HIV are at risk for weight and body changes, introducing opportunities for stigma. Consideration of intersectional stigma related to body size and HIV must be given in any efforts to address weight-related health among women living with HIV.

BACKGROUND:Seventy percent of caloric intake comes from foods prepared at home, suggesting it is a powerful influence on food consumption. Consistent environmental cues triggering food consumption, including those in the home food environment (HFE), may promote habit formation. Despite the HFE's influence, there is a limited understanding of the association between the HFE and habits for consuming specific dietary items. This study examines the relationships between HFE and habit strength. METHOD:This secondary analysis leverages data from a maternal-child obesity intervention trial (HABITS) to examine the relationships between the availability of fruits, vegetables, fried foods, and sugar-sweetened beverages (SSB) in the home and the habit strength of consuming these items. Caregivers (N = 148) completed HFE, habit strength, and demographic questionnaires at baseline. Majority of caregivers identified as female (99.3 %), Black or African American (76.4 %), and had an annual income < $30,000. Multiple linear regression models assessed the relationships between the availability of foods in the home and habit strength for consuming those items. RESULTS:The total number of fruits and vegetables in the HFE was associated with habit strength for fruit (β = .216, p = .009) and vegetable intake (β = .179, p = .030). Similarly, fried food items at home were associated with fried food habit score (β1 = 0.269, p = .028). SSB in the HFE did not predict habit strength for SSB consumption (β1 = 0.187, p = .184). DISCUSSION:Our research suggests that available food items in the home were significantly associated with habit strength for consuming those items. These results support public health initiatives to identify practical approaches to improving health behaviors within households.

ObjectiveThe objective of this study was to examine the independent and interactive effects of insulin sensitivity (SI), the acute insulin response to glucose, and diet on changes in fat mass (FM), resting and total energy expenditure (REE and TEE, respectively), and mechanical efficiency, during weight loss, in African American women with obesity.MethodsA total of 69 women were randomized to low-fat (55% carbohydrate [CHO], 20% fat) or low-CHO (20% CHO, 55% fat) hypocaloric diets for 10 weeks, followed by a 4-week weight-stabilization period (controlled feeding). SI and acute insulin response to glucose were measured at baseline with an intravenous glucose tolerance test; body composition was measured with bioimpedance analysis at baseline and week 10; and REE, TEE, and mechanical efficiency were measured with indirect calorimetry, doubly labeled water, and a submaximal bike test, respectively, at baseline and week 14.ResultsWithin the group with low SI, those on the low-CHO diet lost more weight (mean [SE], -6.6 [1.0] vs. -4.1 [1.4] kg; p = 0.076) and FM (-4.9 [0.9] vs. -2.1 [1.0] kg; p = 0.04) and experienced a lower reduction in REE (-48 [30] vs. -145 [30] kcal/day; p = 0.035) and TEE (mean [SE] 67 [56] vs. -230 [125] kcal/day; p = 0.009) compared with those on the low-fat diet.ConclusionsA low-CHO diet leads to a greater FM loss in African American women with obesity and low SI, likely by minimizing the reduction in EE that follows weight loss.

Intervention packages targeting obesity-related conditions often include multiple behavioral and pharmacological components, yet the independent and synergistic effects of these strategies on disease progression remain largely unexplored. Adaptive interventions offer a structured approach to tailoring treatments based on individual responses, but feasibility data in primary care settings are limited. The objective of this pilot Sequential Multiple Assignment Randomized Trial (SMART) was to investigate the feasibility of a 25-week adaptive biobehavioral intervention designed to improve insulin sensitivity among patients with stage 1 obesity. Forty participants were initially randomized to either nutrition counseling (NC) or exercise counseling (EC), both employing a weight-neutral approach. At week 8, insulin sensitivity was reassessed using the Quantitative Insulin Sensitivity Check Index (QUICKI). Participants with a > 5 Findings support the overall feasibility of the SMART design, with high adherence to virtual counseling sessions and favorable participant retention. The study effectively differentiated responders from non-responders at week 8, with responders showing greater improvements in insulin sensitivity. Among non-responders, WLC and metformin provided a potential rescue effect, but overall insulin sensitivity remained lower than at of responders. While NC and WLC were preferred over EC and metformin, adherence to counseling sessions remained high across all interventions, regardless of preference. Metformin adherence posed challenges due to frequent gastrointestinal side effects and difficulties tracking usage. This pilot study supports the feasibility of an adaptive biobehavioral intervention for improving insulin sensitivity among adults with obesity in a primary care setting. However, further refinement is needed to enhance clinical integration, optimize intervention messaging, and improve medication tracking. Findings from this study will inform a second pilot SMART, laying the foundation for a full-scale primary-care embedded intervention delivering personalized, adaptive strategies for improving cardiometabolic health. NCT04392283 on April 19th, 2020.

OBJECTIVE:Disordered eating (DE) increased during the COVID-19 pandemic, and a recent systematic review identified marginalised identity, psychological wellbeing, loneliness, stress, higher body mass index (BMI), and internalised weight bias (IWB) contributing to pandemic-era DE. The present study aimed to extend these findings by evaluating hypothesised contributors to pandemic-era DE while evaluating pandemic era stressors among a single, more diverse sample of university students. METHOD:A diverse cohort of first-year university students (N = 1289, 43.4% White, 24.2% LGBTQ+) were surveyed in Autumn 2021 about the pandemic's impact on health, socialisation, and academic readiness and performance as part of a larger research project. BMI, IWB, loneliness, self-esteem, depression, DE, screen time, and perceived stress measures were collected. General linear and PROCESS mediation models evaluated group differences and mediators of pandemic-era stressors and DE. RESULTS:Depression, self-esteem, stress, and loneliness partially mediated the relationship between pandemic-era stressors and DE. IWB partially mediated associations between Pandemic-era stressors and DE, with higher IWB strengthening this relationship; however, greater media exposure and higher BMI strengthened these findings [Figure] the extent to which IWB mediated the relationship between Pandemic-era stressors and DE. Black students had lower DE than other racial groups, while sexual minority students had higher DE, though this differed across genders. CONCLUSIONS:IWB, loneliness, and psychological distress may exacerbate pandemic-era DE. Further, marginalisation of bodies, genders, and sexual orientations may play a role in pandemic-era DE. These factors may help identify students most at-risk for DE and help target preventive care to kerb rising eating disorders rates.

BACKGROUND:Weight discrimination is associated with poorer health but has not been studied using social network analysis. This is surprising, as discrimination is a highly social phenomenon, and peer relationships are associated with health, discrimination, and behavior. OBJECTIVE:The aim of this study was to analyze relationships between freshman health and weight discrimination in college social networks during October through December 2021. DESIGN:This study used a cross-sectional design to analyze data from the Freshman Life and Student Health project. PARTICIPANTS/SETTING:Participants (n = 1216 [64% of the class]) included freshmen older than 17 years who were living on a mid-sized Southeastern US university campus (55% from racial and ethnic minoritized groups, 69% female, 32% first-generation college students). MAIN OUTCOME MEASURES:Outcomes included disordered eating, physical activity, gym use, alcohol use, loneliness, stress, depression, and self-esteem. STATISTICAL ANALYSES PERFORMED:Discrimination indices were calculated for each participant's unique position in the network on the basis of discriminatory behavior observed and perpetuated by one's direct connections (ie, immediate network) and direct plus indirect connections (eg, friends of friends, peripheral network). Multivariate regressions tested whether these indices were associated with health, while controlling for race, ethnicity, gender, first-generation college status, perceived weight discrimination, body mass index, and network size. RESULTS:Immediate network discrimination related to poorer health (P = .002; partial eta squared [ηp2] = .023), including greater depression (P = .035; ηp2 = .004), disordered eating (P < .001; ηp2 = .013), perceived stress (P = .020; ηp2 = .005), and loneliness (P = .006; ηp2 = .007), plus lower self-esteem (P = .008; ηp2 = .007), and less gym use (P = .012; ηp2 = .006). Similarly, peripheral network discrimination was associated with poorer health (P = .013; ηp2 = .017), including greater disordered eating (P < .001; ηp2 = .010), loneliness (P = .009; ηp2 = .006), and perceived stress (P = .005; ηp2 = .007), and lower self-esteem (P = .003; ηp2 = .008). CONCLUSIONS:Weight discrimination in college social networks is related to poorer mental and behavioral health. Results suggest that network-level weight discrimination is related to poorer health, even after accounting for weight discrimination perceived by the individual.

BACKGROUND:Understanding the impact of nutrition on human aging requires long-term trials in young, healthy, unmedicated adults. As part of the Dietary Approaches for Longevity and Health (DiAL Health) pilot project, we evaluated strategies for recruiting this population for aging-related dietary intervention studies. METHODS:We analyzed recruitment costs to enroll 70 participants (ages 25-49, BMI 22.0-29.9 kg/m2) across two DiAL Health sites and used NHANES data (2017-March 2020) to estimate the proportion of U.S. adults meeting partial trial eligibility. Additionally, a formative study surveyed 492 U.S. adults (≥18 years) to assess interest in aging-focused dietary trials. RESULTS:Of 2049 applicants screened, 70 were enrolled (3.4 %), with recruitment costs of $1572 per participant at site 1 and $625 at site 2. NHANES data revealed only 3.6 % (555/15,560) of adults met partial eligibility criteria, while 2.2 % (11/492) of formative survey respondents met full eligibility. DiAL Health eligible participants were willing to participate in dietary interventions like time-restricted eating or caloric restriction, but willingness declined for longer or more burdensome trials. CONCLUSIONS:Recruiting young, healthy, unmedicated individuals for aging-focused dietary intervention trials is challenging due to low rates of eligibility and enrollment (∼3-4 % of initial applicants enrolled). Longer trials with stricter eligibility are likely to face greater recruitment barriers, highlighting the need for targeted strategies to engage, recruit, and retain this population effectively.

Background:Gamification represents a promising approach for facilitating positive social interactions among groups of individuals and is increasingly being leveraged in physical activity (PA) interventions to promote enhanced intervention engagement and PA outcomes. Although African American (AA) adults experience disparities associated with health conditions that can be ameliorated with increased PA, little is known about how best to culturally target PA gamification strategies for this population. The purpose of this study was to gather perspectives from AA adults residing in the Southeast United States and subsequently identify themes to help inform the cultural adaptation of an existing electronic and mobile health (e/mHealth) gamification- and theory-based PA intervention for teams of insufficiently active AA adults.Methods:An AA moderator facilitated six online focus groups among AA adults (n=42; 93% female; 45.09±9.77 years; 34.40±57.38 minutes/week of reported moderate-intensity equivalent PA), using a semi-structured focus group guide. Drawing from a content analysis approach, transcripts were coded and salient themes were identified.Results:The focus groups revealed the following seven themes: (I) motivation (team-based gamification motivating); (II) accountability (team-based gamification promotes accountability); (III) competition (competitive elements attractive); (IV) weekly challenges (prefer to choose weekly PA challenges); (V) leaderboard feedback (preference for viewing steps and active minutes via a leaderboard); (VI) cultural relevancy (prefer elements reflective of their race and culture that promote team unity); (VII) teammate characteristics (mixed preferences regarding ideal sociodemographic characteristics and starting PA level of teammates).Conclusions:Integrating team-based gamification in an e/mHealth-based PA intervention may be acceptable among AA adults. The identification of specific design preferences and perceptions of the value of the social environment points to the need to consider surface-level and deep structure cultural targeting when developing and further exploring best practices regarding gamified PA interventions for insufficiently active AAs.