Food for LifecOURse equity In maternal Security and Health

Project Summary / Abstract The Food for LifecOURse equity In maternal Security and Health (FLOURISH) Study uses a cross- cutting research design that is widely-applicable to the prevention and treatment of many chronic co-morbidities that disproportionately affect Indigenous women of childbearing age. Through intentional engagement with community stakeholders across all project years, diverse perspectives will be integrated into the research strategy and aims to ensure study findings are relevant, actionable, and yield the greatest potential for reducing severe maternal morbidity and mortality (SMM). Broadly, FLOURISH will elucidate nutritional and non-nutritional behavioral risk pathways linking food insecurity to SMM and related outcomes among Indigenous women during pregnancy and the immediate post-partum period. A primary focus will be the impact of trauma on food insecurity and health risk, as well as the rigorous evaluation and manipulation of dietary intake as an influential pathway, with a special focus on dietary quality, chronic inflammation and dysglycemia. The study will be conducted in Oklahoma, which is home to 39 of the federally- recognized Tribes that comprise the Southern Plains region, in collaborative partnership with the Southern Plains Tribal Health Board. It is comprised of three aims. First, the team will test and refine a conceptual integrated framework of food insecurity and SMM to identify significant structural, social, behavioral, and biological pathways as candidate intervention points. This aim will be accomplished through an observational study (n=350) of pregnant Indigenous women followed to 3-months postpartum. Structural equation modeling will be used to test the study’s overall conceptual multi-level framework of food insecurity and SMM. The final model will be refined through input with community stakeholders. Second, the community-academic research team will develop the FLOURISH intervention, to be adapted from perinatal food is medicine models used in non-Indigenous populations, with an emphasis on whole person health, including stress management and self-care. The FLOURISH intervention will strategically address key nutrition disparities and other health risk behaviors identified as significant path contributors to various drivers of SMM in this specific population. This adaptation will be informed by findings from the first aim, and further refined and finalized through a series of interviews groups with primiparous and multiparous Indigenous women with history of SMM and various community care providers for this population (n=36). A series of focus groups with intended users will solicit final feedback before the intervention is launched. Third, the research team will use a randomized parallel group design (n=150) involving an additional external control comparison group to test the FLOURISH and FLOURISH PLUS (including community healthcare workers) interventions to assess for feasibility, acceptability, and preliminary impact. Participants will be stratified by pre-pregnancy cardiometabolic risk (high versus low). Primary outcomes include excess gestational weight gain with multiple secondary outcomes (prenatal care, post-partum depression, stress, food security, dietary quality, inflammation, and hemoglobin A1c).