Goal setting among women with BMI ≥25 planning a pregnancy involved in motivation and problem solving coaching to promote diabetes prevention program engagement

The purpose of this thesis was to describe the goals that women with overweight/obese BMIs who were planning a pregnancy made while participating in Motivation and Problem Solving (MAPS) counseling focused on enrollment and engagement in the National Diabetes Prevention Program's Lifestyle Change Program (DPP). The DPP is a 12-month program designed to reduce the risk of Type II diabetes in those with diabetes risk factors. Identifying the types of goals that women set while participating in MAPS coaching can help us to understand how to increase enrollment and participation of reproductive-age women in the DPP. Obesity is strongly associated with developing Type II diabetes, and preventing obesity in women prior to pregnancy by addressing healthy behaviors is particularly important because there are unique risks to both maternal and fetal outcomes. Previous studies have shown that women struggle to adhere to lifestyle interventions, but motivational interventions and goal setting can enhance the effectiveness of these interventions. The participants in this study were women from across the Wasatch front who were 18-40 years old, had an overweight or obese BMI, and were planning a pregnancy within the next 24 months. MAPS counselors contacted participants via telephone to identify each woman's strengths and unique situations, and assist them in developing a "wellness plan" with goals set relating to enrolling and participating in DPP. Women received up to five MAPS calls over a 16 week span. An analysis of the goals that the women set with their counselors revealed two categories of goals: DPP program participation-related goals and lifestyle goals. A total of 47 out of 48 women set a goal at their first MAPS Session. The most common goals at the first MAPS session were related to enrollment in the DPP program (64.6%) and nutrition (41.2%). A total of 46 out of 47 and 38 out of 41 women set goals at their second and third MAPS sessions, respectively. The most common goals for MAPS session 2 were engagement with the DPP program (51.1%) and goals related to nutrition (42.6%), while the most common goals for MAPS session 3 were engagement with the DPP program (36.6%), nutrition (29.3%), and using the Health Slate app provided by the DPP (29.3%). A total of 20 out of 34 women set goals during MAPS call four and the most common goals were related to exercise (32.4%), nutrition (23.5%), and meeting with a DPP facilitator for assistance (23.5%). One woman out of four made goals during MAPS call five, and her goals were related to nutrition (25.0%) and meeting with a MAPS facilitator for support (25.0%). Overall, the most common DPP program participation goals were enrollment and engagement while the most common lifestyle goals were related to nutrition, exercise, and weight. Identifying where reproductive-age women commonly sought assistance with their goals during this study can help distinguish where this under-researched population can be supported as they strive to prevent obesity and Type II diabetes.

Goal Setting Among Women with BMI ≥25 Planning a Pregnancy Involved in Motivation and Problem Solving Coaching to Promote Diabetes Prevention Program Engagement by Maren Busath A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirements for the Honors Degree in Bachelor of Science In Nursing Approved: ___ _________ Sara Simonsen PhD, CNM, MSPH Thesis Faculty Supervisor _____ ______ Melody Krahulec BSN, DNP, MSNEd Assistant Dean for Undergraduate Programs _______________________________ Lauri Linder PhD, APRN, CPON, FAAN Honors Faculty Advisor _____________________________ Monisha Pasupathi PhD Dean, Honors College April 2025 Copyright © 2025 All Rights Reserved i ABSTRACT The purpose of this thesis was to describe the goals that women with overweight/obese BMIs who were planning a pregnancy made while participating in Motivation and Problem Solving (MAPS) counseling focused on enrollment and engagement in the National Diabetes Prevention Program’s Lifestyle Change Program (DPP). The DPP is a 12-month program designed to reduce the risk of Type II diabetes in those with diabetes risk factors. Identifying the types of goals that women set while participating in MAPS coaching can help us to understand how to increase enrollment and participation of reproductive-age women in the DPP. Obesity is strongly associated with developing Type II diabetes, and preventing obesity in women prior to pregnancy by addressing healthy behaviors is particularly important because there are unique risks to both maternal and fetal outcomes. Previous studies have shown that women struggle to adhere to lifestyle interventions, but motivational interventions and goal setting can enhance the effectiveness of these interventions. The participants in this study were women from across the Wasatch front who were 18-40 years old, had an overweight or obese BMI, and were planning a pregnancy within the next 24 months. MAPS counselors contacted participants via telephone to identify each woman’s strengths and unique situations, and assist them in developing a “wellness plan” with goals set relating to enrolling and participating in DPP. Women received up to five MAPS calls over a 16 week span. An analysis of the goals that the women set with their counselors revealed two categories of goals: DPP program participation-related goals and lifestyle goals. A total of 47 out of 48 women set a goal at their first MAPS Session. The most common goals at the first MAPS session were related to enrollment in the DPP program (64.6%) and nutrition ii (41.2%). A total of 46 out of 47 and 38 out of 41 women set goals at their second and third MAPS sessions, respectively. The most common goals for MAPS session 2 were engagement with the DPP program (51.1%) and goals related to nutrition (42.6%), while the most common goals for MAPS session 3 were engagement with the DPP program (36.6%), nutrition (29.3%), and using the HealthSlate app provided by the DPP (29.3%). A total of 20 out of 34 women set goals during MAPS call four and the most common goals were related to exercise (32.4%), nutrition (23.5%), and meeting with a DPP facilitator for assistance (23.5%). One woman out of four made goals during MAPS call five, and her goals were related to nutrition (25.0%) and meeting with a MAPS facilitator for support (25.0%). Overall, the most common DPP program participation goals were enrollment and engagement while the most common lifestyle goals were related to nutrition, exercise, and weight. Identifying where reproductive-age women commonly sought assistance with their goals during this study can help distinguish where this under-researched population can be supported as they strive to prevent obesity and Type II diabetes. TABLE OF CONTENTS ABSTRACT ​ ​ ​ ​ ​ ​ ​ ​ ​ i INTRODUCTION ​ ​ ​ ​ ​ ​ ​ ​ 1 METHODS​ ​ ​ ​ ​ ​ ​ ​ ​ 5 RESULTS ​ ​ ​ ​ ​ ​ ​ ​ ​ 9 DISCUSSION ​ ​ ​ ​ ​ ​ ​ ​ 19 REFERENCES ​ ​ ​ ​ ​ ​ ​ ​ 23 1 INTRODUCTION Obesity is strongly associated with developing Type II diabetes as 89.8% of Americans diagnosed with Type II diabetes are overweight or obese (Centers for Disease Control and Prevention [CDC], 2020). In 2019, 35.5% of US adults who are 18 years or older were categorized as overweight and 29.2% of adults who are 18 years or older were categorized as obese. That means that over half, or 64.7% of US adults are overweight or obese (Centers for Disease Control and Prevention [CDC], 2020). Preventing obesity in reproductive-age women is particularly important because there are unique risks associated with obesity and reproductive health. Women who are obese are two to three times more likely to develop infertility compared to women of normal weight (Grodstein et al., 1994). Obesity in women who are pregnant is linked to many complications including macrosomia, preeclampsia, or gestational diabetes mellitus (Catalano & deMouzon, 2015). Negative birth outcomes associated with obesity include spontaneous abortion, dystocia, fetal distress, and cesarean section (Jacobsen et al., 2012). There is also a link between maternal obesity and the increased risk of metabolic syndrome in the offspring (Boney, 2005). The health risks for both mothers with overweight/obese BMIs and their babies are serious, but they can be preventable. Weight classes are determined by BMI, which is the relationship between weight and height. Overweight is classified as a BMI of 25.0-29.9 and obesity is classified as a BMI of ≥30.0. A study conducted by Catalano and deMouzon (2015) found that adopting lifestyle changes, including dietary and exercise changes, during pregnancy reduced excessive weight gain, but there was no effect on reducing the development of macrosomia, preeclampsia, or gestational diabetes mellitus. 2 However, adopting healthy lifestyle changes before conception can prevent diabetes and reduce these negative health consequences, which may result in better maternal and neonatal outcomes. If women who are planning a pregnancy but are not yet pregnant enroll in evidence-based lifestyle change programs such as the National Diabetes Prevention Program’s Lifestyle Change Program (DPP), these negative health outcomes could be avoided when the woman later becomes pregnant. ​ The DPP is an evidence-based program run by the Centers for Disease Control and Prevention with a goal to promote at least 5% weight loss, at least 150 minutes of weekly physical activity, and prevent the development of Type II diabetes in high-risk populations. High risk populations include those who are physically inactive with a diagnosis of hypertension or gestational diabetes, or a family history of Type II diabetes. Individuals of certain races or ethnicities are also at a higher risk of Type II diabetes. These include American Indians, Latinos, Asians, and African Americans (CDC, 2020). The CDC found that the DPP reduced the risk of developing Type II diabetes by 58% for those below 60 years old, or 71% for those over 60 (U.S. Department of Health and Human Services). The DPP utilizes a curriculum that includes lessons, trained lifestyle coaches, and a support group of peers. The program lasts for one year with meetings once a week for the first six months, and meetings once or twice a month for the second 6 months. The curriculum focuses on making healthy and maintainable dietary changes, implementing physical exercise into a daily routine, and learning to deal with stress. Programs are offered online, in person, or a combination of in person/online with all options offering multiple opportunities for one-on-one interaction with the lifestyle coach (CDC, 2020). Studies have shown that the DPP was a more effective intervention in 3 preventing diabetes than Metformin, a medication used to treat Type II diabetes (Knowler et al., 2002). Additionally, those who participated in more than 17 DPP sessions were able to achieve the weight loss goal of 5%, with an overall 35.5% of participants meeting the weight loss goal (Ely et al., 2017). Increasing enrollment and participation in DPP can improve health outcomes, especially if underserved populations such as reproductive-aged women, who are less likely to enroll and engage in DPP than older women (Ritchie et al.,2017), are targeted. However, due to barriers to DPP participation, reproductive-aged women may benefit from supplemental Motivation and Problem Solving (MAPS)-based counseling to promote DPP enrollment and engagement. MAPS is an approach that facilitates behavior change by using both motivational enhancement and social cognitive approaches. MAPS counseling has been found effective by utilizing goal setting and motivational interventions (Constantino et al., 2009). This program can be tailored to specific populations as it uses trained counselors who help the participants identify their unique skills in order to set goals and problem solve when issues arise (W.R. & S., 2002). For example, reproductive-age women are likely to experience time-poverty, or a lack of time to dedicate to implementing lifestyle changes because they may have childcare and housework responsibilities in addition to working outside the home (Hyde et al., 2020). MAPS counselors are trained to help these women problem-solve in their unique situations to help them overcome barriers to participation in the DPP. Setting goals has been found to be effective for initiating and maintaining habits. One study found that when women established realistic goals to increase their physical activity with a mentor, they were better positioned to maintain their levels of physical 4 activity. The researchers found that when the women in the study kept their goals and rewarded themselves when they accomplished their goals, they were more likely to maintain their physical activity levels (Mendoza-Vasconez et al., 2021). Another study found that when making goals about physical activity, women had more success in increasing their physical activity levels when their goals were about sense of well-being and stress reduction rather than about weight loss and health benefits (Segar et al., 2008). Setting goals for exercise is much more effective than simply engaging in physical activity; women are four times more likely to report maintained levels of physical activity when they set goals relating to their exercise than women who don’t set goals for their exercise (Saajanaho et al., 2014). The MAPS program allows for women to create their own goals and report their success. The purpose of this thesis is to identify the types of goals that reproductive-age women who are planning a pregnancy make during MAPS counseling related to DPP enrollment and engagement. Analyzing these goals can provide information about how to increase reproductive-age women’s enrollment and engagement in DPP as reproductive-age women are half as likely to enroll in this program and also half as likely to engage in multiple sessions compared to older women who are not of reproductive-age (Ritchie et al.,2017) . There is a lack of research on reproductive-age women and their participation in DPP, so understanding what goals these women are making can be the key to supporting them as they work to prevent diabetes for their health and the health of their offspring. 5 METHODS This thesis was part of a larger study which was designed to analyze the effectiveness of utilizing Motivational and Problem Solving (MAPS) counseling to increase enrollment and engagement in theNational Diabetes Prevention Program’s Lifestyle Change Program (DPP) among women with overweight/obese BMIs between the ages of 18-40 who were planning a pregnancy in the next two years. This thesis describes the types of goals women made during their telephone MAPS counseling sessions. Participants in the program were offered free MAPS counseling as well as free enrollment in the DPP. Participants were recruited through social media via healthy4babystudy on Instagram, Twitter, and Facebook. Eligible participants were those who self-identify as women, who are Utah residents, are 18-40 years old, have a BMI ≥25.0, and who are planning to become pregnant in the next two years. In order to promote a diverse participant sample, similar numbers of White/Non-Hispanic and Hispanic/Non-White women who spoke Spanish or English were recruited. Women already diagnosed with Type I or Type II diabetes mellitus were excluded from the study. Women who were interested in the study were directed to a screening survey to determine whether enrollment was appropriate. If the women were deemed eligible, they were contacted to obtain informed consent. Participants then completed an online REDCap baseline survey that was offered in both English and Spanish to collect demographic information, medical history, and current lifestyle habits. Participants answered questions about time spent assisting or caring for children or adults, their medical history, healthcare access, activity level, daily habits, neighborhood and 6 transportation access, social support, and perceived stress. Participants self-reported their medical history about past pregnancies, infertility, gestational diabetes, abortions, and miscarriages. Women who submitted the survey received tools and compensation, including a Fitbit activity tracker, digital scale, free MAPS coaching, free enrollment in the DPP, and $20 compensation for baseline, two month, and four month surveys. The Fitbit activity tracker and digital scale are customary for participants in DPP to track their weight and physical activity. The HealthSlate app was offered through University of Utah Health to those who selected an online version of the DPP. This app offered tools to track physical activity, food intake, and weight as well as access to online health coaching and DPP webinars. Following baseline data collection, participants were contacted by trained health sciences students serving as MAPS coaches via telephone. The MAPS coaches were trained to promote enrollment and engagement in DPP by identifying each individual woman’s unique traits and helping them set goals and problem solve. All of the participants received up to five MAPS coaching telephone calls that lasted between 20 and 30 minutes during the 16 weeks following enrollment in the study. The schedule and frequency of telephone calls was determined between the women and coach. Counseling calls were more frequent at the beginning of the study as the participant considered enrolling in the DPP. If the participant was interested in enrolling, the MAPS coach assisted her with the enrollment. The cost of enrollment in the DPP was covered by the pilot study. After enrollment in DPP, the MAPS counseling calls became less frequent as the participants began engaging in the DPP and the DPP curriculum. During the MAPS calls, the women and coach developed a “wellness plan” that involved individualized 7 goal setting as well as planning for potential barriers or problems and practical problem solving to address these issues. In subsequent calls, women reported on their success in completing their goals and revised their goals as applicable. MAPS counselors were trained to address barriers to success or concerns that the women had, including transportation, interpersonal issues, family problems, and financial concerns. All MAPS sessions were audio recorded and were uploaded to the study database (REDCap) along with the wellness plans that the MAPS coach helped the participants to develop. The HealthSlate app was used to track participation in the DPP and the data from the REDCap survey was integrated with data from the app for analysis. The CDC tracks progress in the DPP by using milestones; we used these same milestones in the study. According to Figure 1, participants reach Milestone One by registering for DPP and setting a password for the HealthSlate App. They reach Milestones Two and Three by completing at least two of the following: (A) Complete two education modules; (B) Send at least one In-App message and/or Group Wall post; (C) Set or log at least one behavior; (D) Log, plan, or research at least three meals; (E) Log physical activity at least three times; (F) Weigh in on three or more days during two out of the first four sessions. Milestone Two is accomplished by meeting the above criteria in two out of the first four weeks and Milestone Three is accomplished by meeting the same criteria in any two weeks between weeks five and nine. Participants reach the final milestone, Milestone Four, by losing 5% of their starting weight anytime after week ten and logging this weight in the HealthSlate App using a Bluetooth scale. 8 Figure 1 DPP Milestones This thesis involved secondary analysis of data from the larger study to gain an understanding about the types of goals that women set as they participated in MAPS coaching sessions focused on DPP enrollment and engagement. This analysis was limited to English speaking participants. During MAPS calls, coaches encouraged participants to identify up to three goals to try to accomplish before the next call. There were no guidelines limiting what kinds of goals were made and participants were not required to make any goals if they did not wish to. The coaches then input the goals that the participants identified from each call into REDCap using free text. The goals were then extracted from REDCap into an Excel sheet. The goals were qualitatively analyzed using conventional content analysis to determine the categories for goals. Conventional content analysis involves determining categories as one is immersed in the data. The categories flow from the data as the analyzer notices patterns (Kleinheksel et al., 2020). The categories for goals were derived directly from the Excel sheet where MAPS coaches 9 reported goals. From this Excel sheet, members of the research team made codes to categorize goals and then went through the sheet and applied the codes to each goal. Then a data set with frequencies for each goal for each MAPS call was created and Excel was used to create graphs to show the distribution of goal categories across MAPS sessions. Tables were then created to display the number and percent of participants reporting each category of goal at each MAPS session. RESULTS A total of 52 women enrolled in the study, and 48 participated in at least one MAPS call. All 48 women who participated in one or more MAPS sessions created at least one goal during a MAPS session with a coach and were included in the analysis for this thesis. A total of 46/48 women enrolled in the DPP; all selected the online DPP available through the University of Utah. Table 1 outlines participant demographics. The women had an average age of 29 years with a range from 20 to 39. The participants came from a diverse sample with 13 participants (27.1%) identifying as Hispanic. A total of 35 (72.9%) women identified as white, four (8.3%) identified as Black or African American, one (2.1%) identified as Native American Pacific Islander. Additionally, there were five (10.4%) who selected “other” and three (6.3%) who selected more than one race. Forty four women (91.7%) were motivated to enroll in the study in order to improve their health, and 39 women (81.3%) were motivated to lose weight. Almost all of the women (91.7%) had completed some college or technical school or higher. Thirty two women (66.7%) reported working for an employer and 16 women (33.3%) reported being a homemaker. Of the women, 31 10 (67.4%) reported working 30 or more hours per week. At the beginning of the study, most of the women (62.5%) reported being very interested in enrolling in DPP while only two (4.2%) reported being definitely not interested. A little over half of the women (56.3%) had previously been pregnant. There was a roughly balanced distribution of the timing for which each woman was hoping to become pregnant (either a first or subsequent pregnancy) with the most common time frame being three to six months (25.0%) and 20.8% wishing to be pregnant in six to 12 months. Four women (8.3%) wanted to become pregnant in nine to 12 months, seven women (14.6%) wanted to become pregnant in 12 to 18 months, and four women (8.3%) wanted to become pregnant in 18-24 months. The most commonly reported health condition was depression or other mental health conditions (e.g., anxiety, bipolar disorder) with fourteen (29.2%) women reporting they had been diagnosed. Eight women (30.8%) reported having asthma or other breathing problems and wheezing. The average BMI of the women was 33.7 with a range from 25.6 -54.9. Table 1 Demographic Characteristics of 48 Reproductive-Age Women with Overweight/Obese BMIs Who Were Planning a Pregnancy Characteristic n(%) Hispanic Yes No 13 (27.1) 35 (72.9) Race White 35 (72.9) 11 Black/ African American Native American Pacific Islander Other More than 1 Race 4 (8.3) 1 (2.1) 5 (10.4) 3 (6.3) Motivations to Enroll Money To improve my health To learn more about health My friends were enrolling To lose weight Other 4 (8.3) 44 (91.7) 23 (47.9) 3 (6.3) 39 (81.3) 4 (8.3) Education Less than high school High school graduate Some college or technical school College graduate Advanced graduate degree 0 (0.0) 4 (8.3) 15 (31.3) 22 (45.8) 7 (14.6) Employment Working for an employer Self-employed Student Homemaker Actively looking for work Unemployed 32 (66.7) 9 (18.8) 3 (6.3) 16 (33.3) 3 (6.3) 2 (4.2) Hours Worked Less than 20 hours 20-30 hours 30-40 hours More than 40 hours I prefer not to answer 7 (15.2) 6 (13.0) 15 (32.6) 16 (34.8) 2 (4.3) Interest in DPP I’m very interested I’m a little interested I’m not sure I’m not really interested I’m definitely not interested 30 (62.5) 13 (27.1) 3 (6.3) 0 (0.0) 2 (4.2) Previous Pregnancy Yes No 27 (56.3) 20 (41.7) 12 When would you like to become pregnant again 3-6 months 6-9 months 9-12 months 12-18 months 18-24 months >24 months Don’t know/not sure Health Conditions Asthma (breathing problems/wheezing) Rheumatoid Arthritis Cancer Cardiovascular Disease Depression or other mental health conditions (anxiety, bipolar) High Blood Pressure Iron Deficient Anemia Thyroid Disease (hyper- or hypothyroid) Other 12 (25.0) 10 (20.8) 4 (8.3) 7 (14.6) 4 (8.3) 8 (16.7) 3 (6.3) 8 (16.7) 1 (2.1) 0 (0.0) 0 (0.0) 14 (29.2) 4 (8.3) 3 (6.3) 6 (12.5) 7 (14.6) The categories of goals were divided into two groups. One group titled “Program Participation” consisted of goals relating to the DPP or MAPS coaching. Goals in this category were related to DPP enrollment, DPP engagement, DPP facilitator, the HealthSlate app, and MAPS itself. DPP enrollment goals included goals made to enroll in the DPP. When enrolling in the DPP, participants received assistance from a MAPS coach. Goals regarding DPP engagement referred to watching online DPP webinars. DPP facilitator goals were made to engage with the DPP facilitator. This included checking in with the facilitator to report success in goals, asking for help creating exercise and nutrition goals, and asking for assistance navigating the online DPP platform and HealthSlate app. The HealthSlate app was provided to all participants who enrolled in the DPP so they could track physical activity, food intake, and weight as well as access to 13 online health coaching and DPP webinars. Goals made regarding usage of the app included consistently tracking weight, food intake, and weight. MAPS goals included goals set to participate in more MAPS calls with coaches. The second category of goals identified was lifestyle goals. This included goals related to nutrition, exercise, weight, sleep, and support system goals. When goals about nutrition were made, this included goals to track food intake and caloric intake, eat more servings of fruit and vegetables, meal prep for the week, stop snacking after dinner, drink more water, and eat healthy snacks. The goals made that were categorized as an exercise goal included meeting a certain step count everyday, going to the gym a certain number of times a week, using the FitBit provided by the study, logging exercise time, going to daily walks, standing and moving more at work, and lifting more weights. Another lifestyle goal category included goals about weight. Goals about weight included using the digital scale provided by the study to weigh themselves consistently, tracking weights, maintaining a certain weight, losing weight, and hitting a certain goal weight. Goals categorized as sleep included tracking sleep, creating a sleep schedule, and increasing the amount of sleep each night. The support system classification was created for a goal that a participant made to discuss goals with her husband. Table 2 describes how many women made goals in different categories across MAPS sessions. There were 48 women who had a MAPS call one and of these, 47 set at least one goal. The most common goal made at MAPS call one was to engage with the DPP program with 31 women (64.6%) making goals to engage. The second most common goals made were regarding nutrition with 20 women (41.2%) making goals about their nutrition. Goals related to DPP engagement, exercise, and weight were also 14 common with 12 (25.5%), 11 (22.9%), and eight (16.7%) women making these goals, respectively. One woman did not make any goals during MAPS session one. For MAPS call two, 47 women participated and 46 set one or more goals. The most common goals made in MAPS call two were related to DPP engagement with 24 women (51.1%) making engagement goals and in close second, nutrition goals with 20 women (42.6%) making these goals. During MAPS session two, one woman (2.1%) did not make any goals. There was a more even spread of goals made during MAPS session three among the 41 women who participated and 38 who made at least one goal, with five categories having a large distribution of the women making these goals. Fifteen women (36.6%) made goals to engage with DPP, 12 women (29.3%) made goals to use the HealthSlate app, 12 women (29.3%) made goals about their nutrition, 11 women (26.8%) made goals to improve their exercise, and 10 women (24.4%) made goals to contact and receive assistance from the DPP facilitator. Three women did not make any goals during the third MAPS session. During MAPS session four, 34 women participated, and 20 set goals. The most common goals made were regarding exercise with 11 women (32.4%) making these goals. The second most common categories were related to contacting the DPP facilitator and improving nutrition, both having 8 women (23.5%) making these goals. A notable 14 women (41.2%) made no goals during this session. Only four women completed MAPS call five in this study. One woman (25.0%) made one goal to improve her nutrition and one goal to contact the DPP facilitator. Three women (75.0%) made no goals during this session. Table Two describes the distribution of goal categories across MAPS sessions. Table 2 15 Distribution of Goal Categories Across MAPS Sessions Goal Category MAPS 1 MAPS 2 MAPS 3 MAPS 4 MAPS 5 N (%) N (%) N (%) N (%) N (%) 31 (64.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 11 (25%) 24 (51.1%) 15 (36.6%) 5 (14.7%) 0 (0.0%) Facilitator 0 (0.0%) 9 (19.1%) 10 (24.4%) 8 (23.5%) 1 (25.0%) MAPS 2 (4.2%) 0 (0.0%) 1 (3.2%) 0 (0.0%) 0 (0.0%) App 3 (6.3%) 10 (21.3%) 12 (29.3%) 5 (14.7%) 0 (0.0%) Nutrition 20 (41.2%) 20 (42.6%) 12 (29.3%) 8 (23.5%) 1 (25.0%) Exercise 11 (22.9%) 10 (21.3%) 11 (26.8%) 11 (32.4%) 0 (0.0%) Weight 8 (16.7%) 9 (19.1%) 5 (12.2%) 1 (2.9%) 0 (0.0%) Sleep 0 (0.0%) 0 (0.0%) 2 (4.9%) 0 (0.0%) 0 (0.0%) System 0 (0.0%) 1 (2.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) No Goals 1 (2.1%) 1 (2.1%) 3 (7.3%) 14 (41.2%) 3 (75.0%) DPP Enrollment DPP Engagement DPP Support Figure 2 details the frequency of goals made during MAPS calls regarding participation in the DPP. Thirty-one women made goals during the first MAPS call session to enroll in the DPP. This decreased to zero women who made goals to enroll in MAPS during call two, three, four, and five. During MAPS call one, 24 women made 16 goals to engage with DPP. A total of 24 women made goals to engage in DPP in MAPS call two, 15 women made goals to engage with DPP in MAPS call three, and five women made goals to engage in MAPS call four. No women made goals to engage with DPP in MAPS call 5. During the first MAPS call, no women made goals to contact the DPP facilitator. A consistent number of women made goals to contact the facilitator during MAPS calls two, three, and four with nine women making the goals in MAPS session two, 10 women in MAPS session three, and eight women in MAPS session four. Only one woman made a goal to engage with the DPP facilitator in MAPS session five. In MAPS call one, only three women made goals to use the HealthSlate app. This increased to 10 women in MAPS call two, 12 women in MAPS call three, and five women in MAPS call four. No women made goals to engage with the app in MAPS call five. Three women made goals to schedule and participate in more MAPS calls. Two women made these goals in MAPS call one and one woman made this goal in MAPS call three. 17 Figure 3 describes the frequency at which women made goals about lifestyle changes during their MAPS calls. In both MAPS session one and two, 20 women made goals about nutrition. This decreased to 12 women making nutrition goals in MAPS call three and then eight women in MAPS call four. Only one woman made a nutrition goal during MAPS call five. The number of women who made goals about exercise remained very consistent until MAPS call five. Eleven women made goals regarding exercise in MAPS call one, three, and four and 10 women made exercise goals during MAPS call two. No women made a goal to exercise in MAPS call five. Fewer women made goals about weight compared to goals about nutrition and exercise. Eight women made a goal related to weight during the first MAPS call, nine women made a weight goal during the second MAPS call, and five women made a weight goal during the third MAPS call. MAPS call four and MAPS call five saw a large decrease in weight goals with one woman making a goal regarding weight and no women making a goal regarding weight, respectively. Goals related to sleep were uncommon in the study. Only one woman made a goal about sleep in MAPS session one, and two women made a goal to sleep during MAPS call three. No women made a goal regarding sleep in MAPS call two, four, and five. One woman made a goal to discuss her goals with her husband during MAPS call two so that was categorized as a support system. There were no other similar goals made. 18 The DPP tracks participants using the milestones as described in figure 3. A total of 46 out of 48 participants (95.8%) achieved milestone one by registering for DPP and 40 out of 45 participants (88.9%) achieved milestone two. One person became pregnant and withdrew from the DPP and will not be counted along with the two participants who did not enroll in DPP from milestone 2 and on. Milestone three saw 33 out of 45 participants (73.3%) accomplish it. 17 out of 44 participants (38.6%) reached milestone four. Another participant became pregnant after milestone three and was therefore not counted towards the milestone four data. DISCUSSION This study found common goal categories made amongst reproductive-age women who were planning a pregnancy and were invited to participate in the DPP. Goals regarding participation in the DPP included enrollment and engagement in the DPP, 19 utilizing tracking tools provided by the study, and receiving assistance from a DPP facilitator. Lifestyle goals included goals about nutrition, exercise, weight, sleep, and using support systems. Understanding the types of goals that reproductive-age women made after being invited to participate in the DPP could help to identify areas where this unique population requires support in order to increase their engagement. Lifestyle goals were a common trend seen among goals set by women in the study. According to Mendoza-Vasconez et al. (2021), physical activity levels can be increased when goals are made with facilitators who help identify realistic goals that will help target long-term fitness maintenance. With these realistic goals that helped address potential barriers to success, women were more likely to independently maintain their physical activity goals after the intervention of facilitators ended. Setting exercise goals is much more effective than simply engaging in physical activity; women are four times more likely to report maintained levels of physical activity when they set goals relating to their exercise than women who don’t set exercise goals (Saajanaho et al., 2014). Reproductive-age women are half as likely to enroll in DPP and also half as likely to engage in multiple sessions, but when they do participate and engage, they equally benefit from weight loss as are older women who participate in DPP (Ritchie et al.,2017). Among a group of women who were eligible to participate in DPP but declined to enroll, women who enrolled in DPP but did not complete the program, and and healthcare providers who treat women eligible for DPP, they identified that cost of the program, required time to dedicate, inconvenient program locations, and DPP not meeting the participants’ expectations as barriers for engagement with DPP (Baucom et al., 2021). In this study, MAPS coaches were able to identify barriers for DPP participation with 20 participants and help address those barriers through goal-setting and practical problem solving. According to Ritchie et al., (2021), when participants of DPP set flexible, self-selected goals they were able to improve their hyperglycemia even when weight loss goals were not met compared to when participants did not set their own goals and only followed the preset goals of DPP (≥5% weight loss and ≥150 minutes of vigorous weekly physical activity). Setting personalized goals while participating in DPP can increase levels of engagement with the program. A limitation of this study is that the sample of participants came from a small sample size of 48 women in Utah, all of whom were planning a pregnancy. This could lead to a unique collection of goals among the participants that are specific to this population compared to women who are not planning a pregnancy. Additionally, there were no assumptions made when coding goal categories. For example, unless the word “app” was explicitly stated in the goals made during MAPS sessions, it was not coded as being a goal related to using the app even though some women could have used the word “track” to refer to the app. Results could also have been affected because not all women participated in all five MAPS sessions. All 48 women participated in the first session but only four women participated in the fifth MAPS session. Lastly, this was a highly motivated group of individuals as all participants had previous desire to make lifestyle changes, and all but 2 enrolled in DPP which could be different among a group of women who aren’t as motivated to participate in lifestyle change. Some strengths of the study include that it tracked goals over a number of weeks as women were beginning to participate in lifestyle changes. Furthermore, all MAPS 21 coaching was assessed for fidelity by a trained psychologist and all coaches adhered to strict protocol for MAPS calls. Also, there has been little research about reproductive-age women’s participation in the DPP, and this study focuses on a group who could benefit greatly from participation. Understanding the goals set by this subset of women who are under-researched could be useful to understand how to help women engage in the DPP nationally. This thesis aimed to identify what a unique population of women needed support with in order to enroll and engage in the DPP and successfully make lifestyle changes to address obesity and prevent Type II diabetes before pregnancy. These women showed that early in the MAPS process, they asked for assistance enrolling in and engaging with the DPP. As the program progressed and they were participating more with the DPP, they shifted to creating goals regarding lifestyle changes. Implementing MAPS coaching could help women enroll and engage with the DPP when they otherwise would not. The DPP is an evidence-based program that is underutilized, especially by reproductive-age women who could benefit greatly from preventing potential health complications before pregnancy, and it is important to research ways to increase participation among these women. Understanding what women need assistance with as they explore enrolling in DPP and begin to engage with the program could help DPP administrators as they support this group that has low levels of engagement. 22 REFERENCES Baucom, K. J. W., Pershing, M. L., Dwenger, K. M., Karasawa, M., Cohan, J. N., & Ozanne, E. M. (2021). Barriers and Facilitators to Enrollment and Retention in the National Diabetes Prevention Program: Perspectives of Women and Clinicians Within a Health System. Women's health reports (New Rochelle, N.Y.), 2(1), 133–141. https://doi.org/10.1089/whr.2020.0102 Boney, C. M. (2005). Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics, 115(3), e290–e296. https://doi.org/10.1542/peds.2004-1808 Catalano, P., & deMouzon, S. H. (2015). Maternal obesity and metabolic risk to the offspring: why lifestyle interventions may have not achieved the desired outcomes. International Journal of Obesity, 39(4), 642–649. https://doi.org/10.1038/ijo.2015.15 CDC. (2020, May 21). Lifestyle Change Program Details | National Diabetes Prevention Program | Diabetes | CDC. Www.cdc.gov. https://www.cdc.gov/diabetes/prevention/lcp-details.html CDC. (2022, May 17). Adult Obesity Facts. Centers for Disease Control and Prevention; CDC. https://www.cdc.gov/obesity/data/adult.html Centers for Disease Control and Prevention. (2022, September 30). Prevalence of prediabetes among adults. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/prevalence-of-prediabetes.html 23 Constantino, M. J., DeGeorge, J., Dadlani, M. B., & Overtree, C. E. (2009, November). Motivational interviewing: A bellwether for context-responsive psychotherapy integration. Journal of Clinical Psychology. https://pubmed.ncbi.nlm.nih.gov/19739206/ Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A national effort to prevent type 2 diabetes: participant-level evaluation of CDC’s national diabetes prevention program. Diabetes Care, 40(10), 1331–1341. https://doi.org/10.2337/dc16-2099 Grodstein, F., Goldman, M. B., & Cramer, D. W. (1994). Body Mass Index and Ovulatory Infertility. Epidemiology, 5(2), 247–250. https://doi.org/10.1097/00001648-199403000-00016 Hughes, R. C. E., Rowan, J., & Williman, J. (2018, March 3). Prediabetes in pregnancy, can early intervention improve outcomes? A feasibility study for a parallel randomized clinical trial. BMJ Open 8(3), e018493. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855392/ Hyde, E., Greene, M. E., & Darmstadt, G. L. (2020). Time poverty: Obstacle to women’s human rights, health and sustainable development. Journal of Global Health, 10(2). https://doi.org/10.7189/jogh.10.020313 Jacobsen, B. K., Knutsen, S. F., Oda, K., & Fraser, G. E. (2012). Obesity at age 20 and the risk of miscarriages, irregular periods and reported problems of becoming pregnant: the Adventist Health Study-2. European Journal of Epidemiology, 27(12), 923–931. https://doi.org/10.1007/s10654-012-9749-8 24 Kleinheksel, A. J., Rockich-Winston, N., Tawfik, H., & Wyatt, T. R. (2020). Demystifying content analysis. American Journal of Pharmaceutical Education, 84(1), 7113. https://doi.org/10.5688/ajpe7113​:contentReference[oaicite:0]{index=0}. Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin , J. M., Walker, E. A., & Nathan, D. M. (2002, February 7). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine 346(6), 393–403. https://pubmed.ncbi.nlm.nih.gov/11832527/ Mendoza-Vasconez, A. S., Badii, N., Becerra, E. S., Crespo, N., Hurst, S., Larsen, B., Marcus, B. H., & Arredondo, E. M. (2021). Forming habits, overcoming obstacles, and setting realistic Goals: a qualitative study of physical activity maintenance among Latinas. International Journal of Behavioral Medicine. https://doi.org/10.1007/s12529-021-10011-3 NIH. (2019, March 8). Diabetes Prevention Program (DPP) | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-preventi on-program-dpp Perrault, L., & Laferrère, B. (2023, June 27). UpToDate. Www.uptodate.com. https://www.uptodate.com/contents/overweight-and-obesity-in-adults-health-cons equences?search=overweight%20and%20obesity&source=search_result&selected Title=1~150&usage_type=default&display_rank=1#H1257166508 25 Ritchie, N. D., Sauder, K. A., Kaufmann, P. G., & Perreault, L. (2021). Patient-centered goal-setting in the national diabetes prevention program: A pilot study. Diabetes Care, 44(11), 2464–2469. https://doi.org/10.2337/dc21-0677 Ritchie, N. D., Sauder, K. A., & Sabbri, S. (2017, September 18). Reach and effectiveness of the National Diabetes Prevention Program for Young women. american journal of preventive medicine. https://pubmed.ncbi.nlm.nih.gov/28928038/ Saajanaho, M., Viljanen, A., Read, S., Rantakokko, M., Tsai, L.-T., Kaprio, J., Jylhä, M., & Rantanen, T. (2014). Older women’s personal goals and exercise activity: An 8-year follow-up. Journal of aging and physical activity, 22(3), 386–392. https://doi.org/10.1123/japa.2012-0339 Segar, M. L., Eccles, J. S., & Richardson, C. R. (2008). Type of physical activity goal influences participation in healthy midlife women. Women’s health issues, 18(4), 281–291. https://doi.org/10.1016/j.whi.2008.02.003 Sharma, K., Akre, S., Chakole, S., & Wanjari, M. B. (2022). Stress-induced diabetes: A review. Cureus, 14(9), e29142. https://doi.org/10.7759/cureus.29142 Vidrine, J. I., Reitzel, L. R., Figueroa, P. Y., Velasquez, M. M., Mazas, C. A., Cinciripini, P. M., & Wetter, D. W. (2013). Motivation and problem solving (MAPS): Motivationally based skills training for treating substance use. Cognitive and behavioral practice, 20(4), 501–516. https://doi.org/10.1016/j.cbpra.2011.11.001 W.R., M., & S., R. (2002). APA PsycNet. Psycnet.apa.org. https://psycnet.apa.org/record/2002-02948-000 26 Name of Candidate: Maren Busath Date of Submission: