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Nutrition Research 28 (2008) 13 20 www.elsevier.com/locate/nutres

A nutrition and physical activity intervention promotes weight loss and enhances diet attitudes in low-income mothers of young children
Kristine C. Jordan a , Jeanne H. Freeland-Graves a,, Deborah M. Klohe-Lehman a , Guowen Cai a , V. Saroja Voruganti a , J. Michael Proffitt a , Henry J. Nuss a , Tracey J. Milani a , Thomas M. Bohman b
a b

Division of Nutritional Sciences, 1 University Station, A2700, The University of Texas at Austin, Austin, TX 78712 Center for Social Work Research, The University of Texas at Austin, 1 University Station R5000, Austin, TX 78712 Received 16 June 2006; revised 16 November 2007; accepted 16 November 2007

Abstract The purpose of this study was to evaluate a nutrition and physical activity program for reducing body weight and improving nutrition attitudes in mothers of young children. A convenience sample of 114 intervention mothers and 33 comparison mothers was recruited from public health clinics and community centers. Eligibility criteria included Hispanic, African American, or white ethnicity; body mass index of at least 25 kg/m2; low income (b200% of the federal poverty index); and youngest child aged 1 to 4 years. For intervention participants, height, weight, percentage of body fat, waist circumference, demographics, nutrition attitudes, and dietary intake were measured at weeks 0 and 8; height, weight, percentage of body fat, and waist circumference were reassessed at 6 months. Overweight mothers in the comparison group provided anthropometric and demographic data at weeks 0 and 8. Changes in anthropometrics, attitudes, and dietary intake were evaluated in intervention mothers. Anthropometric data of intervention vs comparison group mothers were examined. Differences in anthropometrics and attitude scores between weight loss responders (2.27 kg) and nonresponders (b2.27 kg) were assessed at week 8. Intervention participants lost weight (x = 2.7 kg; P b .001), whereas comparison mothers gained a slight amount of weight (x= 0.1 kg) by week 8. Weight loss responders had healthier eating attitudes (5.6 vs 5.2; P b .01) and fewer perceived barriers (2.4 vs 2.9; P b .05) than nonresponders postintervention. In conclusion, this dietary and physical activity curriculum is a valuable resource for weight management programs serving low-income women. 2008 Elsevier Inc. All rights reserved.
Keywords: Mothers; Obesity; Nutrition attitudes; Weight loss; Low-income

1. Introduction The United States is facing an unprecedented epidemic of obesity. Approximately 22.9% of Americans were considered obese, as defined by a body mass index (BMI) of 30 kg/m2 in 1988 to 1994 (NHANES); this increased to
Corresponding author. Tel.:+1 512 471 0657; fax: +1 512 471 5844. E-mail address: jfg@mail.utexas.edu (J.H. Freeland-Graves). 0271-5317/$ see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2007.11.005

30.4% in 1999 to 2002 [1]. The percentage of overweight adults (BMI 25) in the United States has paralleled this trend, rising from 55.9% to 65.1%. Overall, the prevalence of obesity is higher among women [1], minorities [2], and persons of lower socioeconomic status [3]. Among racial groups, African American and Hispanic women incur higher rates of obesity (49.0% and 38.4%, respectively) than whites (30.7%) [1]. The concern with obesity is the increased risk for a variety of chronic diseases, including diabetes mellitus,

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stroke, cancer, hypertension, sleep apnea, and cardiovascular disease [4]. Most weight loss interventions have studied middle to upper income white women [5], but it is low-income women who comprise the majority group giving birth in the United States [6]. In addition, minorities may experience lower rates of weight loss. For example, African American women, as compared to whites, are less likely to participate in a weight loss program, have lower rates of weight loss in these programs, and are more likely to drop out [7]. Participation by low-income and minority women is problematic because of barriers such as program cost, lack of childcare, and family responsibilities [8]. Strategies for promoting weight loss in minorities have included low-literacy materials [9,10], meal replacement shakes [7], culturally sensitive curriculums [11,12], churchbased classes [13], improvements in nutrition knowledge [12,14], behavior modification [7,10], and aerobic exercise [15]. Components of behavior modification include selfmonitoring with food diaries [12], social support [11], the use of rewards [13], and self-efficacy training [16]. Nutrition attitudes may play a more important role in determining food behavior than knowledge alone. According to a meta-analysis of the literature by Axelson et al [17], there is a weak correlation between nutrition knowledge and dietary behavior (r = 0.10). Other factors, such as nutrition attitudes (beliefs about healthful foods, perceived barriers to healthful eating, emotional cues associated with eating), taste preferences, cultural norms, and behavioral capability, act at the intrapersonal level to influence food choices [18]. However, few studies have evaluated the association between nutrition attitudes and weight loss in interventions targeted at low-income populations. Fitzgibbon et al [19] conducted an obesity intervention with 24 African American mothers and daughters. The 6-week curriculum covered the following topics: health consequences of obesity, fast food, fat content of foods, and nutrition labels. Although participants increased their nutrition knowledge by the end of the program, their nutrition attitudes did not improve. However, a companion article to this study found that enhancements in healthful eating attitudes were associated with greater weight loss at week 8 in a triethnic sample (Hispanic, African American, white) of low-income mothers (n = 114) [20]. Other interventions have found improvements in nutrition attitudes in the areas of dietary fat reduction [21,22], cancer prevention [23,24], and fruit and vegetable consumption [25,26]. The justification to investigate the relationship between weight loss and nutrition attitudes is supported by recent research indicating that obese women at 1 year postpartum reported greater barriers to healthful eating and increased eating associated with emotional cues than normal weight women [27]. Clearly, effective interventions targeted toward lowincome women are needed to combat the rising prevalence of obesity and diabetes in the US. According to the Surgeon General's call to action to prevent and decrease overweight

and obesity [28], the development of culturally appropriate interventions to treat obesity is a high priority area for the US public health system. Thus, the overall purpose of this research is to assess the impact of the program on reducing body weight in low-income mothers to decrease the prevalence of obesity in this population. In addition, our study aims to identify (1) nutrition attitudes associated with weight loss and (2) correlations between nutrition attitudes and dietary factors. 2. Methods and materials 2.1. Design The intervention was designed to provide pre- and postmeasurements for a convenience sample of overweight or obese (BMI 25 kg/m2) mothers (n = 114) of young children. In intervention subjects, height, weight, percentage of body fat, waist circumference, demographics, attitude, and dietary measures were obtained at weeks 0 and 8; program evaluation forms were collected at week 8; and height, weight, percentage of body fat, and waist circumference were reassessed at week 24 for a subsample of 93 participants who were able to attend a follow-up measurement session. Participants were divided into responders (2.27 kg) or nonresponders (b2.27 kg) based on the amount of weight loss at week 8 [12]. A comparison group of mothers with a similar BMI (25 kg/m2) volunteered to provide comparison data for demographic and anthropometric measures at weeks 0 and 8 only. Data on attitudes and dietary assessment were unavailable for the comparison group. The comparison group did not receive any educational intervention. Weight loss at week 8 was considered the primary end point; however, weight was reevaluated at week 24 in intervention mothers who could still be contacted to assess weight maintenance. All subjects gave informed consent before participation in the study, and the institutional review board at the University of Texas (Austin, TX) approved the research protocol. 2.2. Subjects Mothers of young children were recruited from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, community centers, and churches to participate in free weight loss classes or serve as comparison subjects. Eligibility criteria for both groups included African American, white, or Hispanic ethnicity; youngest child of 1 to 4 years; BMI of at least 25 kg/m2; low-income (qualification for WIC or food stamps or annual household income b200% of the federal poverty index); and absence of breast-feeding (b5 min/d). The final intervention sample size was 114 of 260 who came to the first class, for an attrition rate of 56%. For mothers who completed the 8-week program, the class attendance rate was 87%. Dropouts did not differ from intervention subjects on baseline characteristics, except that dropouts were less likely to be living with a spouse/partner (61% vs

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81%, P b .05) or to be employed (60% vs 74%, P .01). In addition, 33 overweight/obese comparison mothers of similar demographic background provided anthropometric data at weeks 0 and 8. 2.3. Intervention classes Small group classes were held at clinics and community centers. Each 2-hour class incorporated recommendations for healthful eating, behavior modification, and physical activity that were based on suggestions following focus group discussions. The educational objectives for the intervention included the following: list the benefits of weight loss, monitor portion sizes to allow for weight loss, self-monitor via food records and pedometers, interpret nutrition labels for energy and fat content, modify recipes to decrease calories, select nonfood rewards for attaining goals, promote improvement in attitudes about nutrition (increase concern for the nutritional content of foods, describe cues associated with emotional eating, propose solutions to address emotional eating and barriers to healthful eating, identify sources of stress that trigger eating, explain how to stop a food binge), demonstrate strength-building exercises, and describe techniques to help maintain weight loss. The dietary recommendations were based on the US dietary guidelines that were designed to encourage healthful eating habits and regular physical activity [29,30]. The healthful eating component consisted of menu plans with culturally appropriate foods, portion control, and food budget guidelines. Prescribed energy intakes ranged from 5021 to 6276 kJ/d. Energy calculations for weight loss were obtained by subtracting 2092 kJ from the Harris-Benedict equations using adjusted body weight [31]. Mothers had the option of lowering their energy intake, increasing their physical activity levels, or integrating both strategies. A variety of resources were offered to participants, including exchange lists, calorie and fat counters, detailed menus, walking plans, and strength training routines. Behavioral aspects of weight management presented included social support, stimulus control, contingency management, and stress management [32]. The third part of the curriculum, physical activity, consisted of 30-minute inclass exercise sessions and class discussions as described by Clarke et al [33]. In addition, these recommendations for diet, physical activity, and behavior modification were tailored to each participant by providing feedback on diet recalls, pedometer records, and behavior modification worksheets. The curriculum was based on the social cognitive theory by Bandura [34]. This theory proposes that dynamic and reciprocal interactions between cognitions, behaviors, and the environment determine the actions of individuals. Specifically, the intervention promoted a healthier environment (increased availability of healthful foods and support for regular physical activity) by affecting mothers' cognitions and behaviors. Mothers' cognitions were altered by setting weight loss goals and increasing knowledge of the energy content of foods, nutrition label guidelines, meal

planning, and recipe modification. Behavioral changes included increased self-efficacy for healthful eating and exercise, enhanced social support by other mothers, increased self-control to manage problem eating and exercise behaviors, and role modeling for observational learning. Different constructs of the theory were addressed in each class. For example, the opening class strived to raise awareness of the benefits of weight loss and healthful eating (outcome expectations); the cooking demonstration class aimed to enhance the knowledge and skills for meal preparation (behavioral capability); and the stress management class focused on the strategies to control binge eating (emotional coping responses). Additional information on the classes is detailed in Klohe-Lehman et al [35]. 2.4. Anthropometric measurements Height was determined with a stadiometer (Perspective Enterprises, Portage, MI), and weight was measured with an electronic weighing scale (Model HS-100-A, Fairbanks Scales, St Johnsbury, VT). Body mass index was calculated as kilogram per square meter. Percentage of body fat was assessed via bioimpedance with a body composition analyzer (Model TBF-300A, Tanita Corporation, Arlington Heights, IL). Waist circumference was obtained by positioning a measuring tape around the abdomen at the highest lateral border of the right iliac crest, as recommended by NHANES III [36]. 2.5. Dietary assessment Intervention mothers reported a 24-hour diet recall and 2 days of food records at weeks 0 and 8, and a 24-hour recall weekly during each class. The weekly 24-hour recalls were conducted for self-monitoring to provide feedback on dietary intakes. Subjects were provided with oral and written instructions by registered dietitians who used measuring spoons and cups for portion size estimation. Nutrient data were analyzed via Food Processor 7.81 (2001, ESHA Research, Salem, OR). Nutrient values were modified with the Software for Intake Distribution Estimation (Side, version 1.0, 2002, Ames, IA). This software corrected for the variability in daily consumption and produced adjusted estimates of usual intake distributions. 2.6. Survey methods The Nutrition Attitudes Scale consisted of 21 items with 4 subscalessensory motivators, emotional eating, perceived barriers, and healthful eating [27]. The sensory subscale encompassed taste, hunger, and cravings as motivators for eating. The emotional eating subscale assessed eating in response to states of depression, stress/ anxiety, and anger. Perceived barriers included dislike of low-fat foods, less healthful family preferences, confusion regarding nutrition guidelines, too much effort, employment, and lack of interest in changing habits. The healthful eating subscale incorporated items pertaining to the enjoyment and importance of nutritious foods. Items were

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evaluated according to a Likert scale ranging from 1 = least important to 7 = very important (sensory motivators, perceived barriers, healthful eating) or 1 = never to 7 = always (emotional eating responses). Each subscale score consisted of the average sum of items in the subscale. Higher scores represented more of the measured trait. Factor analysis was used to demonstrate validity of the subscales. Reliability of the subscales varied from fair for sensory motivators ( = .65) to very good for promoters of healthful eating ( = .86). In addition, demographic data were elicited with a 40-item questionnaire adapted from Walker et al [37]. 2.7. Statistical methods The SPSS software (version 11.5, 2003, SPSS Inc, Chicago, IL) was used to analyze data. Entered data were checked for accuracy, scanned for missing values, evaluated for the presence of outliers, and assessed for normality of distribution. Analyses were conducted with consideration of all available data. Statistical significance was shown only if the probability (P) values were less than .05.

Baseline differences on demographics and anthropometrics between groups (intervention and comparison, intervention and program dropouts, intervention responders and nonresponders) were assessed using the 2 or Fisher exact test and independent-sample t test [38]. Changes in anthropometrics, attitudes, and nutrients for intervention subjects were evaluated with the paired t and Wilcoxon signed rank tests. Differences in anthropometrics and attitude scores between weight loss responders and nonresponders at week 8 were assessed with analysis of covariance, adjusting for pretest values. Relationships between weight loss and continuous and categorical variables were tested with Pearson and Spearman correlation coefficients, respectively. 3. Results The demographic profile of intervention subjects by weight loss responder category vs nonintervention comparison mothers is shown in Table 1. Overall, the mean ages of the intervention responders, nonresponders, and comparison mothers were 27.5, 27.0, and 30.8 years, respectively. The

Table 1 Baseline demographic profile of participants enrolled in a nutrition and physical activity intervention for low-income mothers based on weight loss responder category vs nonintervention comparison mothers Characteristic Intervention group (n = 114) Responders (n = 60) n Age (y) 18-24 25-29 30-39 40 BMI (kg/m2) 25.0-29.9 30.0-34.9 35.0-39.9 40.0 Educational level High school not completed High school graduate Partial college College/graduate degree Employed Yes No Children in household 1-2 3-4 5 Living with spouse/partner* Yes No 20 20 17 3 % 33.3 33.3 28.4 5.0 Nonresponders (n = 54) n 18 23 9 4 % 33.3 42.6 16.7 7.4 n 10 3 15 5 Comparison group (n = 33) % 30.3 9.1 45.4 15.2

12 23 16 9

20.0 38.3 26.7 15.0

12 19 10 13

22.2 35.2 18.5 24.1

11 7 10 5

33.3 21.2 30.3 15.2

14 18 21 7

23.3 30.0 35.0 11.7

8 16 21 9

14.8 29.6 38.9 16.7

8 11 9 5

24.2 33.3 27.3 15.2

49 11

81.7 18.3

44 10

81.5 18.5

28 5

84.8 15.2

42 15 3

70.0 25.0 5.0

37 16 1

68.5 29.6 1.9

17 14 2

51.5 42.4 6.1

50 10

83.3 16.7

34 20

63.0 37.0

18 15

54.5 45.5

Responders significantly different from nonresponders and overall intervention group (responders + nonresponders) significantly different from comparison group at *Pb .05 as determined by the 2 test.

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Table 2 Anthropometric measurements of participants enrolled in a nutrition and physical activity intervention for low-income mothers based on weight loss responder category vs nonintervention comparison mothers Variable Intervention group (n = 114) Responders (n = 60) Week 0 Weight (kg) Body fat (%) Waist circumference (cm) 91.9 18.9 43.1 5.7 106.1 16.9 Week 8 87.2 19.0 41.3 6.3a 101.2 16.6b
a

Comparison group (n = 33)

Nonresponders (n = 54) Week 0 92.1 21.5 43.0 6.0 108.2 18.5 Week 8 91.6 21.4 42.5 6.0a 106.2 18.3b
a

Week 0 90.4 19.4 43.2 5.3 106.9 14.2

Week 8 90.5 19.8a 42.9 6.4 106.9 13.7b

Common superscripted letter (a) within a row indicates significant differences, with responders significantly different than nonresponders and overall intervention group (responders + nonresponders) significantly different than comparison group for week 8 data at P b .001 as determined by analysis of covariance, adjusting for week 0 value. Common superscripted letter (b) within a row indicates significant differences, with responders significantly different than nonresponders and overall intervention group (responders + nonresponders) significantly different than comparison group at P b .01.

average BMI differed little for the responder, nonresponder, and overweight comparison groups (34.7, 35.3, and 34.4) and did not vary by ethnicity. Among responders, 63% were Hispanic, 14% were African American, and 23% were white, as compared to 65%, 26%, and 9% for nonresponders, and 49%, 39%, and 12% for comparison mothers, respectively. The majority of subjects were employed, graduated from high school, and had 1 to 2 children living at home. More than 80% of responders were living with a partner as opposed to 63% of the nonresponders (P b .05). Furthermore, the overall intervention sample of responders and nonresponders was more likely to cohabitate with a partner than the comparison group (74% vs 54%, P b .05). Most responders (97%), nonresponders (100%), and comparison mothers (85%) qualified for WIC services and reported an annual household income less than $29,999 (72%, 79%, and 62%, respectively). The anthropometric changes for the intervention group by responder category vs nonintervention comparison mothers are displayed in Table 2. Initially, the mean body weight for responders, nonresponders, and comparison mothers was 91.9, 92.1, and 90.4 kg, with similarities in body fat (43%) and waist circumference measures (range, 106-108 cm). As a result of the 8-week program, responders significantly decreased weight (x = 4.7 kg; median, 8.8 kg; P b

.001), body fat (x = 1.8%; P b .001), and waist circumference (x = 4.9 cm; P b .001) to a greater extent than nonresponders (weight [x = 0.5 kg; median = 1.4 kg; P b .05], body fat [x = 0.5%], and waist circumference [x = 2.0 cm; P b .05]). For the overall intervention sample, the declines in body weight (x = 2.7 kg; median = 2.4 kg; P b .001), body fat (x = 1.2%; P b .001), and waist circumference (x = 3.5 cm; P b .001) were highly significant. Ninety-eight participants (86%) lost weight; 1 person (1%) maintained the same weight; 15 individuals (13%) gained weight. Furthermore, for intervention subjects available at follow-up (week 24), the declines in body weight (x = 2.7 kg; P b .001), percentage of body fat (0.8%; P b .01), and waist circumference (12.1 cm; P b .001) remained significantly lower than baseline. In contrast, the overweight comparison mothers gained a slight, but nonsignificant, amount of weight during the 8-week intervention period (x = 0.1 kg). Fig. 1 displays the changes in motivators for eating and nutritional attitudes for participants. At baseline, the sensory motivators were rated as greater influences on eating than were attitudes regarding health, emotions, and barriers. However, healthful attitudes ranked higher than sensory motivators by the end of the program. Subjects reported

Fig. 1. Motivations for eating and nutritional attitudes of intervention mothers by weight loss responders (n = 60) and nonresponders (n = 54) at weeks 0 and 8. Error bars represent SDs. Responders significantly differ from nonresponders for week 8 values at P b .01 (double asterisk) and P b .05 (asterisk) as determined by analysis of covariance, adjusting for week 0 score.

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more favorable attitudes toward healthful eating, reduced emotional eating, and fewer perceived barriers at postintervention than at baseline. In addition, differences in attitudes were observed by weight loss responder categories. Those who lost at least 2.27 kg reported a greater emphasis on healthful eating attitudes and fewer perceived barriers than nonresponders (b2.27 kg). The subscale of healthful eating attitudes represented items that were not easily comparable; however, all items improved as a result of the intervention. Examples of these healthful eating questions included I enjoy low-fat foods and I am very concerned with the nutritional content of foods. With the subscale of emotional eating, intervention participants associated depression and stress/anxiety more often with overeating (78% and 70%, respectively) than anger (59%). By postintervention, women were less likely to eat more when depressed (63%) or angry (56%); however, overeating associated with stress exhibited little change (68%). For the perceived barrier subscale, subjects initially ranked the dislike of low-fat foods (68%), confusion regarding nutrition (68%), and family preferences (58%) highest among barriers. These all decreased upon program completion. Several improvements in dietary intakes were related to changes in perceived barriers to healthful eating. A greater consumption of dairy foods was negatively related to perceived barriers (r = 0.22; P b .05). In addition, mothers who increased their dairy servings reported less confusion regarding nutrition (r = 0.28; P b .01) and fewer complaints of the effort required to eat healthful foods (r = 0.26; P b .01). Also, subjects who decreased their cholesterol intake by postintervention reported less difficulty in changing their dietary habits (r = 0.24; P b .01). Further information on the dietary results of the intervention was detailed in Clarke et al [39]. Overall, the weight loss intervention was rated highly. More than 90% of participants reported learning a great deal from the program. In particular, women stated that the inclass exercise (88.3%), weekly weigh-ins (85.3%), and wearing a pedometer (84.7%) were very useful components. Suggestions for future classes included establishing maintenance classes, offering more cooking classes, and providing the program in Spanish. 4. Discussion Few studies have assessed the impact of a nutrition and physical activity intervention on weight loss while examining nutrition attitudes in a population of low-income mothers. Our intervention produced significant reductions in weight, percentage of body fat, and waist circumference. These reductions are noteworthy because weight loss is very challenging, especially for low-income populations. The mean weight loss at 8 weeks was comparable to other studies involving minorities such as Kanders et al [7] (2.9 kg) and Kumanyika and Charleston [13] (2.7 kg). Weight loss was higher in this study than that for Domel et al [12] (1.4 kg),

Mayer-Davis et al [15] (1.2 kg), and Sullivan and Carter [40] (0.2 kg) and lower than that for Ard et al [11] (6.7 kg), Kaul and Nidiry [9] (6.4 kg), and McNabb et al [10] (4.4 kg). That mothers were able to maintain significant decreases in weight, percentage of body fat, and waist circumference for 6 months shows that this program has potential for promoting lasting health benefits in this population. This study is unique for its comparison of sensory and behavioral attitudes of nutrient intake by low-income women. At baseline, mothers reported a greater influence of sensory motivators, such as taste and hunger, on eating choices rather than specific attitudes. It is well established that taste is a major reason for food selection [41]. However, our sensory subscale did not change as a result of the intervention. This lack of change was not unexpected because sensory factors are largely influenced by biological mechanisms [42]. Upon program completion, healthful eating concerns superseded sensory attributes as the most important motivator for eating. The reduction in emotional eating and perceived barriers at the end of the intervention corroborate other enhancements in attitudes by mothers enrolled in studies targeting cancer prevention [23,24], dietary fat reduction [21,22], and fruit and vegetable consumption [25,26]. In contrast, Fitzgibbon et al [19] did not find significant changes in nutrition attitudes in an obesity prevention study for African Americans. The authors attributed this result to the small sample size of 24 participants and short treatment duration of 6 weeks. The improvements in perceived barriers toward healthful eating are believed to have contributed to the positive dietary changes observed in this study. The associations between attitudes and dietary behavior do not prove a cause and effect relationship but support the proposition by Bandura [34] that cognitive changes interact with behavior. Limitations of this study include its high attrition and short treatment period. Yet, the attrition rate for this program (56%) is within the range of 23% to 80% experienced in other studies recruiting minorities [9,10,12,13,15,43]. Factors influencing attrition in this program included illness of a child, lack of childcare, transportation difficulties, job conflicts, financial constraints, family responsibilities, insufficient time, lack of family support, personal stress, and respondent burden of the questionnaires. These barriers to participation precluded a longer intervention and have been documented in previous research with low-income women [8]. Although we attempted to minimize these issues by providing a free program, offering makeup classes, and varying class times and locations, obstacles remained. In summary, a curriculum was developed to promote weight loss in a population of low-income mothers. Significant declines in weight, percentage of body fat, and waist circumference were observed. Furthermore, we found that weight loss responders improved their attitudes toward healthful eating and reduced their perceived barriers to healthful eating to a greater extent than nonresponders by

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postintervention. These results demonstrate that a lifestyle program can promote weight loss in low-income mothers. Therefore, public health clinics should consider adopting weight management programs for their clients. Acknowledgment This research was supported by a grant from the Texas Higher Education Coordinating Board, Austin, TX (UTA#00-377). References
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