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Program Design for Healthy Weight in Lesbian and Bisexual Women: A Ten-City Prevention Initiative

      Abstract

      Purpose

      Adult lesbian and bisexual (LB) women are more likely to be obese than adult heterosexual women. To address weight- and fitness-related health disparities among older LB women using culturally appropriate interventions, the Office on Women's Health (OWH) provided funding for the program, Healthy Weight in Lesbian and Bisexual Women (HWLB): Striving for a Healthy Community. This paper provides a description of the interventions that were implemented.

      Methods

      Five research organizations partnered with lesbian, gay, bisexual, and transgender community organizations to implement healthy weight interventions addressing the needs of LB women 40 years and older. The interventions incorporated evidence-based recommendations related to physical activity and nutrition. Each group intervention developed site-specific primary objectives related to the overall goal of improving the health of LB women and included weight and waist circumference reduction as secondary objectives. A 57-item core health survey was administered across the five sites. At a minimum, each program obtained pre- and post-program assessments.

      Results

      Each program included the OWH-required common elements of exercise, social support, and education on nutrition and physical activity, but adopted a unique approach to deliver intervention content.

      Conclusion

      This is the first time a multisite intervention has been conducted to promote healthy weight in older LB women. Core measurements across the HWLB programs will allow for pooled analyses, and differences in study design will permit analysis of site-specific elements. The documentation and analysis of the effectiveness of these five projects will provide guidance for model programs and future research on LB populations.
      Obesity has been associated with numerous adverse health sequelae (
      • Hu F.B.
      Overweight and obesity in women: Health risks and consequences.
      ,
      • Kulie T.
      • Slattengren A.
      • Redmer J.
      • Counts H.
      • Eglash A.
      • Schrager S.
      Obesity and women's health: An evidence-based review.
      ,
      • Jones G.
      • Sutton A.
      Quality of life in obese postmenopausal women.
      ). More than two-thirds of women in the United States are overweight or obese (
      • Flegal K.M.
      • Carroll M.D.
      • Kit B.K.
      • Ogden C.L.
      Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999-2010.
      ), and lesbian and bisexual (LB) women are at greater risk for obesity than heterosexual women (
      • Bowen D.J.
      • Balsam K.F.
      • Ender S.R.
      A review of obesity issues in sexual minority women.
      ,
      • Conron K.J.
      • Mimiaga M.J.
      • Landers S.J.
      A population-based study of sexual orientation identity and gender differences in adult health.
      ,
      • Eliason M.J.
      • Ingraham N.
      • Fogel S.
      • Mcelroy J.
      • Lorvick J.
      • Mauery D.R.
      • Haynes S.
      Systematic review of weight and sexual minority women.
      ,
      • Ward B.W.
      • Dahlhamer J.M.
      • Galinsky A.M.
      • Joestl S.S.
      Sexual orientation and health among U.S. adults: National Health Interview Survey, 2013.
      ). In the 2013 National Health Interview Survey, 37% of adult women who identified as gay or lesbian and 41% who identified as bisexual were obese, compared with 28% who identified as straight or heterosexual (
      • Ward B.W.
      • Dahlhamer J.M.
      • Galinsky A.M.
      • Joestl S.S.
      Sexual orientation and health among U.S. adults: National Health Interview Survey, 2013.
      ). Although the limited statistics do not provide an analysis based on sexual orientation related to age, research demonstrates that as women age, body weight has a tendency to increase (
      • Adams K.F.
      • Leitzmann M.F.
      • Ballard-Barbash R.
      • Albanes D.
      • Harris T.B.
      • Hollenbeck A.
      • Kipnis V.
      Body mass and weight change in adults in relation to mortality risk.
      ). Several cross-sectional surveys, including the National Survey of Family Growth (Cycle 6), the Nurses' Health Study, and the National Institutes of Health–funded Women's Health Initiative, have documented significantly higher rates of overweight and obesity in lesbian women compared with heterosexual women; research suggests this disparity remains true into the later years (
      • Case P.
      • Bryn Austin S.
      • Hunter D.J.
      • Manson J.E.
      • Malspeis S.
      • Willett W.C.
      • Spiegelman D.
      Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II.
      ,
      • Boehmer U.
      • Bowen D.J.
      • Bauer G.R.
      Overweight and obesity in sexual minority women: Evidence from population-based data.
      ,
      • Bowen D.J.
      • Balsam K.F.
      • Ender S.R.
      A review of obesity issues in sexual minority women.
      ,
      Institute of Medicine (IOM)
      The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding.
      ,
      • Valanis B.G.
      • Bowen D.J.
      • Bassford T.
      • Whitlock E.
      • Charney P.
      • Carter R.A.
      Sexual orientation and health: Comparisons in the Women's Health Initiative Sample.
      ,
      • Yancey A.K.
      • Cochran S.D.
      • Corliss H.L.
      • Mays V.M.
      Correlates of overweight and obesity among lesbian and bisexual women.
      ). The National Survey of Family Growth, a population-based survey of persons between the ages of 15 and 44, reported that lesbians had more than twice the odds of overweight and obesity as heterosexual women (
      • Boehmer U.
      • Bowen D.J.
      • Bauer G.R.
      Overweight and obesity in sexual minority women: Evidence from population-based data.
      ). The Nurses' Health Study found disparities in longitudinally assessed weight gain trajectories, with LB women more likely than heterosexual women to experience adverse weight gain in adulthood (
      • Jun H.-J.
      • Corliss H.L.
      • Nichols L.P.
      • Pazaris M.J.
      • Spiegelman D.
      • Austin S.B.
      Adult Body mass index trajectories and sexual orientation: The Nurses' Health Study II.
      ). Lesbian/bisexual women aged 50 to 79 years in the Women's Health Initiative sample of women were 25% more likely to be obese than heterosexual women, with 51% of lesbians being overweight or obese (
      • Valanis B.G.
      • Bowen D.J.
      • Bassford T.
      • Whitlock E.
      • Charney P.
      • Carter R.A.
      Sexual orientation and health: Comparisons in the Women's Health Initiative Sample.
      ). Finally, a recent systematic review of the literature found that LB women had significantly greater body mass index (BMI) or a higher percentage with a BMI of greater than 30 kg/m2 than heterosexual women (
      • Eliason M.J.
      • Ingraham N.
      • Fogel S.
      • Mcelroy J.
      • Lorvick J.
      • Mauery D.R.
      • Haynes S.
      Systematic review of weight and sexual minority women.
      ). This is the first paper of several in the Women's Health Issues supplement on healthy weight in lesbian and bisexual women; the results of the interventions follow this paper in the supplement.
      With virtually no extant national interventions addressing weight and fitness-related health disparities among LB women (
      • Rizer A.M.
      • Mauery D.R.
      • Haynes S.G.
      • Couser B.
      • Gruman C.
      Challenges in intervention research for lesbian and bisexual women.
      ), the United States Department of Health and Human Services, Office on Women's Health (OWH) provided funding for the coordinated national initiative titled: Healthy Weight in Lesbian and Bisexual Women: Striving for a Healthy Community (HWLB program). Healthy weight was defined as the weight at which physical health risks and conditions are decreased to normal ranges or functional and psychosocial status is improved. Previous research identified unique concerns, barriers, and perceptions related to weight interventions among LB women (
      • Bowen D.J.
      • Balsam K.F.
      • Diergaarde B.
      • Russo M.
      • Escamilla G.M.
      Healthy eating, exercise, and weight: Impressions of sexual minority women.
      ,
      • Fogel S.
      • Young L.
      • Dietrich M.
      • Blakemore D.
      Weight loss and related behavior changes among lesbians.
      ,
      • Yancey A.K.
      • Cochran S.D.
      • Corliss H.L.
      • Mays V.M.
      Correlates of overweight and obesity among lesbian and bisexual women.
      ). These include the desire for a safe environment composed of LB women that allows for open discussion about partners or other sexual identity-related concerns, a program design that fosters a sense of community, a focus on achieving health and physical fitness rather than thinness, and a recognition of the specific stressors experienced by LB women. Therefore, the HWLB program focused on improving the overall health of older LB women (women over the age of 40) by tailoring interventions to meet their identified needs (
      • Brittain D.
      • Dinger M.
      • Hutchinson S.
      Sociodemographic and lesbian-specific factors associated with physical activity among adult lesbians.
      ,
      • Fogel S.
      • Young L.
      • McPherson J.B.
      The experience of group weight loss efforts among lesbians.
      ,
      • Roberts S.J.
      • Stuart-Shor E.M.
      • Oppenheimer R.A.
      Lesbians' attitudes and beliefs regarding overweight and weight reduction.
      ).
      Theories that attempt to explain the roots of higher rates of obesity among LB women include stigmatization (including minority stress;
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ); childhood sexual abuse (
      • Aaron D.J.
      • Hughes T.L.
      Association of childhood sexual abuse with obesity in a community sample of lesbians.
      ,
      • Austin S.B.
      • Jun H.-J.
      • Jackson B.
      • Spiegelman D.
      • Rich-Edwards J.
      • Corliss H.L.
      • Wright R.J.
      Disparities in child abuse victimization in lesbian, bisexual, and heterosexual women in the Nurses' Health Study II.
      ); LB community norms that prioritize health over weight loss (
      Fat liberation
      ); rejection of heteronormative standards of thinness, with its associated dieting practices, as representing beauty; positive acceptance of all body sizes; and attraction based on factors other than physical characteristics (
      • Bowen D.J.
      • Balsam K.F.
      • Diergaarde B.
      • Russo M.
      • Escamilla G.M.
      Healthy eating, exercise, and weight: Impressions of sexual minority women.
      ,
      • Chmielewski J.F.
      • Yost M.R.
      Psychosocial influences on bisexual women's body image negotiating gender and sexuality.
      ,
      • Fogel S.C.
      But I have big bones! Obesity in the lesbian community.
      ,
      • Morrison M.A.
      • Morrison T.G.
      • Sager C.-L.
      Does body satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review.
      ,
      • Roberts S.J.
      • Stuart-Shor E.M.
      • Oppenheimer R.A.
      Lesbians' attitudes and beliefs regarding overweight and weight reduction.
      ).
      The purpose of this paper is to describe five individual, yet related, 12- to 16-week-long interventions that demonstrate the feasibility of community-specific interventions for healthy weight among LB women. The results of these specific studies are reported elsewhere (
      • McElroy J.
      • Haynes S.
      • Eliason M.
      • Wood S.
      • Minnis A.
      • Barker L.T.
      • Garbers S.
      Healthy weight in lesbian and bisexual older women: An effective intervention in 10 cities using tailored approaches.
      ). These five pilot studies represent the initial phases of interventions that introduce unique combinations of features (e.g., gym memberships, mindfulness, Health at Every Size, bio/psychosocial measurements) that fit within the IOM's recommendations for achieving a healthy weight. The design and components of each intervention will be described individually with an ensuing discussion and recommendations for practice or policy.

      Materials and Methods

      Study Objectives

      The intent of the HWLB program was to assess a variety of approaches to group interventions that fit within the older LB community. In a systematic review of obesity prevention interventions, those that incorporated both diet and physical activity showed positive impact on weight outcomes over long-term follow-up (
      • Lemmens V.E.P.P.
      • Oenema A.
      • Klepp K.I.
      • Henriksen H.B.
      • Brug J.
      A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults.
      ).
      The use of a cognitive–behavioral approach (using group meetings, individual counseling for nutrition and physical activities, and physical activity programs) is well-grounded in previous weight loss and health improvement/maintenance research (
      • Brawley L.
      • Rejeski W.J.
      • Gaukstern J.E.
      • Ambrosius W.T.
      Social cognitive changes following weight loss and physical activity interventions in obese, older adults in poor cardiovascular health.
      ,
      • Rejeski W.J.
      • Brawley L.R.
      • Ambrosius W.
      • Brubaker P.H.
      • Focht B.C.
      • Foy C.G.
      • Fox L.D.
      Older adults with chronic disease: The benefits of group mediated counseling in the promotion of physically active lifestyles.
      ). Each of the HWLB programs conducted focus groups with LB community members before implementation. This series of 11 focus groups informed participant recruitment and retention strategies and enabled further refinement of each intervention's content (
      • Garbers S.
      • McDonnell C.
      • Fogel S.
      • Eliason M.
      • Ingraham N.
      • McElroy J.A.
      • Haynes S.G.
      Aging, weight, and health among adult lesbian and bisexual women: A metasynthesis of the multisite “Healthy Weight Initiative” focus groups.
      ). To ensure appropriate engagement of LB women and their respective communities, the OWH required awardees to actively partner with lesbian, gay, bisexual, and transgender (LGBT) community organizations focused on addressing the needs of LB women (Table 1). All interventions were required to incorporate four IOM recommendations related to obesity prevention (
      Institute of Medicine (IOM)
      Accelerating progress in obesity prevention: Solving the weight of the nation.
      ). These recommendations included encouraging physical activity, establishing healthy dietary choices, promoting limited intake of alcohol, and reducing intake of sugar-sweetened beverages. Each HWLB program group intervention developed site-specific primary SMART (specific, measurable, appropriate, realistic, and time-specific) objectives related to the overall OWH goal (Table 2). The objective to increase fruits and vegetables by 10% was thought to be achievable, based on the low intake nationwide (≤3 per day) in the intervention states as reported by the Centers for Disease Control and Prevention's 2013 Behavioral Risk Factor Surveillance System (
      • Moore L.V.
      • Thompson F.E.
      Adults meeting fruit and vegetable intake recommendations—United States, 2013.
      ). Reducing sugar-sweetened beverage consumption by 50% was determined to be reasonable for the 12- to 16-week intervention period because between 30% and 50% of the recommended daily limits for women aged 40 to 75 for solid fats and sugars come from sugared drinks (
      Institute of Medicine (IOM)
      Accelerating progress in obesity prevention: Solving the weight of the nation.
      ). The objective for cutting alcohol consumption in half was based on the National Institute of Alcohol and Alcoholism's recommendations to consume 1 drink of alcohol a day (

      National Institutes of Health. (n.d.). Drinking levels defined. National Institute on Alcohol Abuse and Alcoholism. Available: www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. [Retrieved 8th October 2015].

      ). Given the older age and condition of some of the participants, increasing the number of minutes of physical activity by 20% was felt to reflect a minimum goal that would be achievable and have some impact even at the level of walking. This was based in part on a 2007 systematic review of interventions incorporating pedometer use that found an average 26.9% increase in the number of steps taken per day (which for an average person represents a 27% increase in minutes walked) and a concomitant decrease in body weight and blood pressure over an average 18-week intervention period (
      • Bravata D.M.
      • Smith-Spangler C.
      • Sundaram V.
      • Gienger B.
      • Lin N.
      • Lewis R.
      • Sirard J.
      Using pedometers to increase physical activity and improve health: A systematic review.
      ).
      Table 1Healthy Weight in Lesbian and Bisexual Women Program Intervention Names, Partners, and Locations
      Intervention NameLGBT Community PartnersResearch Partners
      Doing It For Ourselves: DIFOSan Francisco LGBT Center

      World Institute on Disability

      Rainbow Women of Oakmont

      SF Openhouse
      IMPAQ International (Oakland, CA)
      Living Out, Living Actively: LOLASAGE (Services & Advocacy for GLBT Elders) - St. Louis

      The Center Project – Columbia
      NORC at the University of Chicago (Chicago, IL) and University of Missouri-Columbia (Columbia, MO)
      Making Our Vitality Evident: MOVEMautner Project: The National Lesbian Health OrganizationThe Jacobs Institute of Women's Health of the George Washington University School of Public Health and Health Services (Washington, DC)
      Strong, Healthy, Engaged: SHESAGE (Services & Advocacy for GLBT Elders) – New York CityThe Lewin Group (New York, NY)
      Women's Health and Mindfulness: WHAMLyon-Martin Health ServicesResearch Triangle Institute (San Francisco, CA)
      Abbreviation: LGBT, lesbian, gay, bisexual, transgender.
      Table 2Site Primary SMART Objectives
      DIFOMOVELOLASHEWHAM
      • 10% increase in quality of life scores (VR-12) for 75% of participants
      • 20% increase in number of minutes of physical activity per week for 75% of participants
      • 10% increase in fruit and vegetable consumption by 80%
      Increase exercise to 150 minutes of moderate or 75 minutes of vigorous exercise per week
      • 10% decrease in BMI for gym group
      • 7% decrease in BMI for pedometer group
      • Across all intervention groups:
        • 10% decrease in alcohol consumption
        • 10% increase in fruit and vegetable consumption
        • 25% decrease in sugar-sweetened beverage consumption
        • 75% increase in percentage of individuals meeting 2008 Physical Activity Guidelines
      • Increase average number of daily steps/day by 2000
      • Increase the percentage of individuals meeting vegetable consumption guidelines to 50%
      • Decrease percentage of individuals who consume sugar-sweetened beverages on a daily basis to 5%
      • 0.05 mean decrease in hemoglobin A1c levels
      • 40% increase in number of individuals meeting 2010 dietary guidelines
      • 30% increase in number of minutes of moderate-intensity physical activity per week
      Abbreviations: BMI, body mass index; DIFO, Doing It for Ourselves; MOVE, Making Our Vitality Evident; LOLA, Living Out, Living Actively; SHE, Strong, Healthy, Energized; SMART, specific, measurable, appropriate, realistic, and time-specific; WHAM, Women's Health and Mindfulness.
      All interventions were also required to include as secondary SMART objectives a 5% reduction in the waist circumference to height ratio (measured by group leaders or the participant using a standardized tape measure;
      • Han T.S.
      • Richmond P.
      • Avenell A.
      • Lean M.E.
      Waist circumference reduction and cardiovascular benefits during weight loss in women.
      ,
      • Janssen I.
      • Katzmarzyk P.T.
      • Ross R.
      Waist circumference and not body mass index explains obesity-related health risk.
      ) and a 5% reduction from baseline weight (measured by group leaders or the participant using a calibrated scale;
      • Kushner R.F.
      • Ryan D.H.
      Assessment and lifestyle management of patients with obesity: Clinical recommendations from systematic reviews.
      ). This decrease in weight was found in the Look AHEAD (Action for Health in Diabetes) study to result after 1 year in a 5% point reduction in hemoglobin A1c, a 5-mm Hg decrease in systolic and diastolic blood pressure, a 5 mg/dL increase in high-density lipoprotein cholesterol, and a 40 mg/dL decrease in triglycerides (
      • Wing R.R.
      • Lang W.
      • Wadden T.A.
      • Safford M.
      • Knowler W.C.
      • Bertoni A.G.
      • Wagenknech L.
      Look AHEAD Research Group
      Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes.
      ). Other reports have also shown improved health with as little as 5% decrease in weight (
      • Blackburn G.
      Effect of degree of weight loss on health benefits.
      ,
      • Kushner R.F.
      • Ryan D.H.
      Assessment and lifestyle management of patients with obesity: Clinical recommendations from systematic reviews.
      ,
      ).
      The institutional review board at each institution approved the protocols and materials. Analysis of the de-identified secondary data was deemed exempt from review by the institutional review board at the Healthy Weight Initiative Coordinating Center.

      Data Collection

      To provide a consistent assessment across the interventions, HWLB programs used a 57-item core survey that took 20 to 25 minutes to complete. The core survey incorporated standardized survey instruments used in previous federal research (whenever possible) to assess demographics (including sexual orientation), dietary habits, physical activity levels, disability status, smoking status, and quality of life (Table 3). In addition, measures addressing program-specific aims were included for each site. Weight, height, and waist circumference were recorded at baseline and immediately after the intervention at each site through direct measurement by research staff or self-report. Although self-report is not as reliable as direct measurement, self-reported weight and waist circumference measures were allowed at three of the program sites for participants who refused to submit to direct measurement by research staff.
      Table 3Source of Items for Healthy Weight in Lesbian and Bisexual Women Program Core Questionnaire
      Core Questionnaire ItemsNumber of ItemsSource
      Demographic questions7NHIS, BRFSS, and Census
      Sexual orientation5NHIS
      Fruit and vegetable consumption7BRFSS
      Smoking status2BRFSS
      Sugar sweetened beverages4NHIS
      Water consumption2National Health and Nutrition Examination Survey (NHANES) II
      Physical activity7International Physical Activity Questionnaire (IPAQ) – Short Form
      Alcohol consumption7National Institute on Alcohol Abuse and Alcoholism
      Quality of life (
      • Selim A.J.
      • Rogers W.
      • Fleishman J.A.
      • Qian S.X.
      • Fincke B.G.
      • Rothendler J.A.
      • Kazis L.E.
      Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12).
      )
      15RAND Veterans Questionnaire (VR-12)
      Disability status2Americans with Disabilities Act
      Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; NHIS, National Health Interview Survey.

      Intervention Profiles

      The five funded HWLB programs were conducted through unique partnerships with LGBT community organizations and established research organizations. The interventions were geographically dispersed with sites located in the San Francisco Bay area in California (5 cities); the Columbia/St Louis area in Missouri (2 cities); the Silver Spring, Maryland/Washington, DC area (2 cities); and New York City (Table 4). Each site drew participants from the surrounding areas, allowing a much larger population to participate.
      Table 4Overview of Healthy Weight in Lesbian and Bisexual Women Program Intervention Locations and Programmatic Components
      InterventionLocation(s)Data Collection Time PointsNumber of Weekly SessionsSession Duration (h)Format of Nutrition ComponentsPhysical Activity Components
      Physical activity components were identified through the IOM 2012 report and focus group data collected during these programs: A = Guided activity during group sessions; B = Gym membership; C = Personal trainer; D = Pedometer.
      Online Resources
      DIFOSan Francisco, CA

      Santa Rosa, CA

      Berkeley, CA

      Sebastopol, CA

      El Cerrito, CA
      Pre- and post-intervention; 4-month follow-up122Group and individualAhttp://difobayarea.org
      LOLAColumbia, MO

      St. Louis, MO
      Pre- and post-intervention; 8-month follow-up161GroupA, B,C, Dhttp://Outproudandhealthy.org
      MOVESilver Spring, MD Washington, DCPre- and post-intervention121.5Group and individualA, B, C, Dhttps://www.whitman-walker.org/service/community-health/mautner-project/
      SHENew York CityPre-and post-intervention121.5GroupA, Dhttp://www.adrc-tae.acl.gov/documents/Final%20SHE%20Participant%20Guide.pdf
      WHAMSan Francisco, CA

      Berkeley, CA
      Pre-and post-intervention122–3Group and individualA, CN/A
      Abbreviations: DIFO, Doing It for Ourselves; MOVE, Making Our Vitality Evident; LOLA, Living Out, Living Actively; SHE, Strong, Healthy, Engaged; WHAM, Women's Health and Mindfulness.
      Physical activity components were identified through the
      Institute of Medicine (IOM)
      Accelerating progress in obesity prevention: Solving the weight of the nation.
      report and focus group data collected during these programs: A = Guided activity during group sessions; B = Gym membership; C = Personal trainer; D = Pedometer.
      Recruitment techniques varied across the programs and included online and traditional media and in-person approaches. Three of the interventions were solely community-based (Doing It For Ourselves [DIFO]; Living Out, Living Actively [LOLA]; Strong, Healthy, Energized [SHE]), and used customary community recruitment techniques. Project information was disseminated through local LGBT groups, allied community groups, and existing networks of project staff, advisory boards, friends, and colleagues for all programs. The two clinic-based locations (Making Our Vitality Evident [MOVE] program and Women's Health and Mindfulness [WHAM]) used electronic medical records to partially or completely identify eligible participants, followed by physician engagement or direct contact. To increase participation numbers, HWLB programs enrolled participants in sequential waves, between October 2013 and October 2014, as opposed to having one start date.
      Eligibility criteria common to all HWLB program sites were: age 40 or over (with 3 sites [DIFO, LOLA, and SHE] giving special emphasis to enrolling women age ≥ 60), identifying as a lesbian or bisexual woman, and meeting weight or BMI requirements (≥25 or 27 kg/m2, DIFO, WHAM, MOVE) or self-identifying as overweight and interested in “getting healthier” (SHE, LOLA). Mobility status was not assessed nor included in the common inclusion criteria. There were no other specific exclusion criteria. In total, 376 women aged 40 to 85 years enrolled in the programs (enrollment defined as providing informed consent, completing a baseline questionnaire, and signing up for a group), of whom 80% identified as lesbian and 13% as bisexual. The remaining 6% of participants selected “something else” as their sexual orientation; 1% did not respond. Overall, 74% of enrolled participants were non-Hispanic White, 9% were non-Hispanic Black, and 9% were Latina/Hispanic (Table 5) and predominantly well educated. Sites were funded independently at varying levels and the size of the individual programs ranged from 17 to 148 participants.
      Table 5Demographic Characteristics of Enrolled Healthy Weight in Lesbian and Bisexual Women Program Participants (n = 376)
      CharacteristicDIFO (n = 148)LOLA (n = 97)MOVE (n = 34)SHE (n = 17)WHAM (n = 80)Total (n = 376)
      n (%)n (%)n (%)n (%)n (%)n (%)
      Age
       Age (y), mean [range]60 [43–84]55 [40–81]51 [40–65]68 [57–84]53 [40–76]57 [40–84]
      Gender
       Female/cis-gender135 (91)93 (96)16 (94)68 (85)312 (92)
       Transgender2 (1)4 (4)0 (0)5 (6)11 (3)
       Other gender identity
      Gender identity question prompts and response options not consistent across sites. One program site (MOVE) did not collect gender identity data. Other gender identities reported include genderqueer, queer, two-spirit, dyke, and not sure of gender identity.
      11 (7)1 (6)7 (9)19 (6)
      Sexual orientation
       Lesbian119 (80)86 (89)25 (74)13 (77)59 (74)302 (80)
       Bisexual21 (14)10 (10)6 (18)1 (6)11 (14)49 (13)
       Something else8 (5)1 (1)3 (9)2 (12)10 (13)24 (6)
       Did not identify0 (0)0 (0)0 (0)1 (6)0 (0)1 (<1)
      Race/ethnicity (categories not mutually exclusive)
       Non-Hispanic White110 (74)88 (91)24 (71)11 (65)45 (58)278 (74)
       Non-Hispanic Black10 (7)4 (4)9 (27)3 (18)6 (8)32 (9)
       Native American1 (1)0 (0)0 (0)0 (0)0 (0)1 (0)
       Asian Pacific Islander4 (3)0 (0)0 (0)0 (0)1 (1)5 (1)
       Latina/Hispanic11 (7)1 (1)1 (3)3 (18)17 (22)33 (9)
       Multiracial/multiethnic12 (8)4 (4)0 (0)0 (0)9 (12)25 (7)
      Employment status
       Full time (≥32 h/wk)50 (34)68 (70)20 (59)0 (0)29 (36)167 (45)
       Part time (<32 h/wk)19 (13)10 (10)9 (27)3 (18)17 (21)58 (16)
       Retired39 (27)13 (13)1 (3)13 (77)5 (6)71 (19)
       Disabled25 (17)2 (2)2 (6)1 (6)19 (24)49 (13)
       Unemployed9 (6)2 (2)2 (6)0 (0)8 (10)21 (6)
       In school full time4 (3)2 (2)0 (0)0 (0)1 (1)7 (2)
       Full time homemaker1 (1)0 (0)0 (0)0 (0)1 (1)2 (1)
      Educational attainment
       Less than high school0 (0)0 (0)0 (0)0 (0)2 (3)2 (1)
       High school or GED2 (1)7 (7)1 (3)4 (24)2 (3)16 (4)
       Technical school – no degree0 (0)2 (2)0 (0)0 (0)0 (0)2 (1)
       Some college – no degree28 (19)16 (17)6 (18)1 (6)21 (26)72 (19)
       2-year college or technical school degree17 (12)6 (6)4 (12)1 (6)5 (6)33 (9)
       4-year college degree26 (18)22 (23)4 (12)2 (12)21 (26)75 (20)
       Post-graduate work or degree74 (50)44 (45)19 (56)9 (53)29 (36)175 (47)
      Health insurance
       Yes138 (94)92 (95)31 (91)17 (100)71 (89)349 (93)
       No9 (6)5 (5)3 (9)0 (0)8 (10)25 (7)
       Do not know0 (0)0 (0)0 (0)0 (0)1 (1)1 (0)
      Out to health care providers
       Out to all118 (80)65 (67)22 (65)6 (35)72 (90)283 (75)
       Out to a few9 (6)3 (3)1 (3)4 (24)1 (1)18 (5)
       Out to some14 (10)25 (26)9 (27)6 (35)5 (6)59 (16)
       Out to none6 (4)3 (3)2 (6)1 (6)2 (3)14 (4)
       Not applicable1 (1)1 (1)0 (0)0 (0)0 (0)2 (1)
      Disability
      Any long-term physical or mental impairment that substantially limits one or more major life activities.
       Yes60 (41)7 (7)8 (24)5 (29)46 (58)126 (34)
       No85 (59)90 (93)26 (77)12 (71)34 (43)247 (66)
      Menopausal status
       Premenopausal (≥1 period in last 12 months)27 (18)31 (32)19 (58)0 (0)24 (30)101 (27)
       Postmenopausal or no period in the last 12 months for other reason121 (82)66 (68)14 (42)17 (100)56 (70)274 (73)
      Smoking status
       Never smoked69 (47)43 (46)16 (47)8 (47)40 (50)176 (47)
       Ever smoked, but not current smoker68 (46)40 (43)13 (38)9 (53)26 (33)156 (42)
       Current smoker7 (5)10 (11)3 (9)0 (0)14 (18)34 (9)
       Not sure of smoking history4 (3)1 (1)2 (6)0 (0)0 (0)7 (2)
      Abbreviations: DIFO, Doing It for Ourselves; MOVE, Making Our Vitality Evident; LOLA, Living Out, Living Actively; SHE, Strong, Healthy, Engaged; WHAM, Women's Health and Mindfulness.
      NOTE: Missing values not presented.
      Gender identity question prompts and response options not consistent across sites. One program site (MOVE) did not collect gender identity data. Other gender identities reported include genderqueer, queer, two-spirit, dyke, and not sure of gender identity.
      Any long-term physical or mental impairment that substantially limits one or more major life activities.
      Three sites (DIFO, LOLA, and WHAM) enrolled a small number of transgender women (n = 11) and participants (n = 19) who reported other gender identities, including genderqueer, a term used by some individuals who identify as neither entirely male nor entirely female (

      National Center for Transgender Equality. (2015). Transgender terminology. Available: http://transequality.org/issues/resources/transgender-terminology. [Retrieved 19th October 2015].

      ). More than one-third of enrolled participants were disabled, defined as long-term physical or mental impairment that substantially limited one or more major life activities (n = 126).
      Although the five OWH-funded HWLB programs each used a distinctive study design, all incorporated a pre–post evaluation design, weekly group meetings, nutrition education, and physical activity as core elements. Two groups (LOLA and DIFO) had an additional follow-up assessment after the intervention period. Three sites (DIFO, LOLA, and WHAM) had comparison groups. Whereas the OWH prioritized funding study designs that included either a control or comparison group, some sites that proposed working with community-based organizations that serve key subgroups of LB women (e.g., older women at SHE or African American women in MOVE) were not large enough to recruit both an intervention group and a control or comparison group and used pre–post designs.
      All sites tailored the content and format of their evidence-based intervention components to the expressed preferences of LB women in their communities (
      • Garbers S.
      • McDonnell C.
      • Fogel S.
      • Eliason M.
      • Ingraham N.
      • McElroy J.A.
      • Haynes S.G.
      Aging, weight, and health among adult lesbian and bisexual women: A metasynthesis of the multisite “Healthy Weight Initiative” focus groups.
      ). Recruitment strategies and materials at all five sites involved the use of culturally tailored messaging to fit the specific cultural characteristics of each distinct community (
      • Wood S.
      • Brooks J.
      • Eliason M.
      • Garbers S.
      • McElroy J.
      • Ingraham N.
      • Haynes S.
      Recruitment and Participation of Older Lesbian and Bisexual Women in Intervention Research.
      ). These strategies and materials are explained within each profile.
      Appendices A through E provide the specific content of the intervention sessions at each site. Group sessions at all sites included time for open discussion of concerns specific to LB women, such as dealing with minority stress (
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ), interacting with health care providers who are unfamiliar with LB-specific health issues (
      • Li C.C.
      • Matthews A.K.
      • Aranda F.
      • Patel C.
      • Patel M.
      Predictors and consequences of negative patient-provider interactions among a sample of African American sexual minority women.
      ), and addressing conflicting community norms about weight (
      • Eliason M.J.
      • Ingraham N.
      • Fogel S.
      • Mcelroy J.
      • Lorvick J.
      • Mauery D.R.
      • Haynes S.
      Systematic review of weight and sexual minority women.
      ). Personal training sessions were tailored to each individual participant and gym-based physical activity components included appropriate cultural competency training given to staff interacting with the LB participants. Nutrition sessions emphasized the role of community and social interaction. Common topics across all sites included defining nutrition, exercise, what constitutes a healthy weight, development of a positive body image, the role of lesbian community norms on health behaviors, and barriers and facilitators to achieving a healthy weight. The next section describes each of the five intervention projects in detail.

      Profile 1: Doing It for Ourselves

      Community partners

      IMPAQ International collaborated with four LGBT community partners as described below.
      • Rainbow Women of Oakmont, a group of more than 100 retirement community residents in Santa Rosa whose goals are to socialize with others having similar life experiences and provide membership education on lesbian-specific issues.
      • The World Institute on Disability (WID), a public policy center emphasizing social and economic equity for people with disabilities, increasing opportunities to live independently.
      • The San Francisco LGBT Center, a nonprofit organization connecting the diverse community to opportunities, resources, and each other to achieve a stronger, healthier, and more equitable world for LGBT people and allies.
      • Openhouse, a nonprofit organization that helps isolated and vulnerable LGBT seniors access sensitive housing, health care, long-term care, and aging-support services.

      Program focus

      DIFO was a peer-led community-based health education and support group designed to promote nutrition, physical activity, and stress reduction, with the primary objective of improving quality of life through building community and addressing minority stress. DIFO was designed as a pre–post intervention study with a 4-month follow-up and a nonrandomized comparison group who did not participate in the intervention.

      Intervention

      Two-hour weekly education and support group meetings took place in five locations (Santa Rosa, Berkeley, San Francisco, Sebastopol, and El Cerrito) in three 12-week waves. Each weekly session had three components: 1) nutritional strategies and tools (adapted from Health at Every Size;
      • Bacon L.
      Health at every size: The surprising truth about your weight.
      ) based on an intuitive eating approach that draws attention to bodily cues about hunger and fullness and tracks the effect of different kinds of foods on mood, pain, and energy (
      • Denny K.
      • Loth K.
      • Eisenberg M.
      • Neumark-Sztainer D.
      Intuitive eating in young adults. Who is doing it, and how is it related to disordered eating behaviors?.
      ,
      • Madden C.
      • Leong S.
      • Gray A.
      • Horwath C.
      Eating in response to hunger and satiety signals is related to BMI in a nationwide sample of 1601 mid-age New Zealand women.
      ,
      • Provencher V.
      • Begin C.
      • Tremblay A.
      Health at every size and eating behaviors: One-year follow up results of a size acceptance intervention.
      ,
      • Tribole E.
      • Resch E.
      Intuitive eating: A revolutionary program that works.
      ); 2) discussion of LB-specific topics based on comprehensive review of lesbian health as outlined in
      • Eliason M.J.
      • Fogel S.
      An ecological framework for understanding sexual minority women's health: Factors related to higher body mass.
      , such as minority stress (stress that is a result of being in a sexual or other cultural or ethnic minority group[s];
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ); and 3) 15 minutes of physical activity, based on a routine developed by a physical therapist and fitness coach to be appropriate for women of any ability level and safe to do in a group setting. The routine focused on core strengthening, spine mobility and body awareness. A DVD of the routine was available for home use and featured older, larger LB women as models. Participants were given homework assignments to track food, physical activity, and stress, asked to practice the physical activity routine, and given access to the detailed manual and DIFO webpage for additional resources. Additional intervention details are provided in Appendix A.

      Unique features

      In addition to intuitive eating, DIFO applied mindfulness, which is a process of bringing a certain quality of attention to moment-by-moment experience as defined by
      • Bishop S.R.
      • Lau M.
      • Shapiro S.
      • Carlson L.
      • Anderson N.D.
      • Carmody J.
      • Devins G.
      Mindfulness: A proposed operational definition.
      , to topics including relationships, physical activity, the body in general, and stress. After the first wave, all subsequent facilitators were graduates of the DIFO program, had undergone a 6-hour training, and were supervised by the project's principal investigator. Finally, DIFO focused attention on understudied populations, including LB women with disabilities and those living in a retirement community with a predominance of other LB women.

      Challenges

      Owing to LB women's cultural resistance to weight loss programs, the Healthy Weight Initiative program title presented a challenge. Although subsequent recruitment materials used “healthy at any size, shape, and ability level” and “women of size” to highlight DIFO's emphasis on health and wellness, many still thought it was code for a weight loss program. Weight and waist circumference measures were required, which also created suspicion and resistance. Participants were given the option of self-collecting weight and waist circumference, with limited success obtaining the latter. Scheduling a 2-hour individual consultation with a fitness coach during the intervention phase was another challenge. Subsequent protocol modifications allowed the fitness coach and group facilitator to collaboratively develop group physical activity plans.

      Profile 2: Project LOLA (Living Out, Living Actively)

      Community partners

      The University of Missouri and NORC partnered with two LGBT community organizations for this study. The Center Project is a nonprofit and volunteer-run organization in Columbia that focuses on the needs of sexual minority residents and allies. The Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) of Metro St. Louis, Missouri, is a nonprofit whose mission is to achieve a high quality of life for sexual and gender minority older adults, support and advocate for their rights, foster a greater understanding of aging in all communities, and promote positive images of the lives of sexual and gender minorities in later years.

      Program focus

      LOLA was designed to determine whether one type of intervention (gym membership with a personal trainer or walking) was more efficacious in improving fitness and health (see Table 2 for specific outcomes), comparing results with an attention control group. Mediators and obstacles to healthier lifestyle choices in physical activity and diet were evaluated as was the potential for long-term change.

      Intervention

      The program's randomized control trial had three arms: full gym group, SMART pedometer group, and the control group. Participants in the full gym group were provided with a 12-month gym membership, 12 personal training sessions of 45 to 60 minutes in duration, and a structured, individualized workout routine for each week designed by an exercise physiologist. SMART pedometer group members were given a Fitbit Zip wireless activity tracker, instructed on how to use it, and asked to wear it throughout the 16-week intervention. Data from the device were automatically downloaded to a customized data collection system. Both the full gym group and the SMART pedometer groups had weekly support meetings and four additional sessions on food choices and nutrition, which they were encouraged to attend. To mimic the other groups' experiences, the control group attended weekly education sessions focusing on women's health issues. Details are provided in Appendix B.

      Unique features

      Although the use of a randomized control trial study design was unique, this project also required a pre-intervention medical examination from a physician and a pre–post in-depth evaluation of body composition and fitness (i.e., aerobic fitness, strength, and flexibility measures using standardized protocol conducted at fitness gyms by trainers) to assess changes among groups and over time. Project LOLA also had an 8-month follow-up (from completion date of the intervention) during which participants completed a third body composition and fitness assessment and a final round of questionnaires. Women in Columbia, Missouri, also obtained fasting blood work, including a complete metabolic profile, lipid profile, and vitamin D status. All participants completed assessments of modifiable lifestyle factors, medical history, and psychosocial factors. At the end of the intervention, participants completed a post questionnaire and second fitness assessment. Focus groups were also held upon study completion at each site to allow participants to share feedback.

      Challenges

      Location was both a strength and challenge. Columbia, Missouri, is a small college town with a close-knit network of LB women. The tightness of the community was a strength for recruitment in wave 1, but made it more difficult in wave 2, because saturation was reached quickly. St. Louis is known for its enclaves that segregate areas and groups of people, making recruitment and information dissemination challenging. Unique to St. Louis, another challenge for recruitment and then participation was the travel time required to participate in the study and competing events or activities. Another unanticipated challenge was the time required (median, 46 days) to schedule the initial medical examination by their primary care doctor.

      Profile 3: The MOVE (Making Our Vitality Evident) Program

      Community partners

      George Washington University partnered with the Mautner Project. Founded in 1988 as an independent nonprofit organization dedicated to improving lesbian, transgender, and gender-nonconforming people's health and cancer care support, education, and advocacy, the Mautner Project merged in 2013 with Whitman-Walker Health (a health center with special expertise in LGBT care and care for those with human immunodeficiency virus infection in the Washington, DC, metro area) and centralized its care and wellness programs at Whitman-Walker Health.

      Program focus

      The MOVE program was a hybrid of clinical and community-based health education and support programs in two locations: Silver Spring, Maryland, and the District of Columbia. MOVE was designed to promote sound nutrition choices and physical activity through social support and health education to assist participants in reaching a healthy weight through behavior and lifestyle change. MOVE evaluated changes in physical activity, use of an online fitness program, and changes in weight and waist circumference, using a pre- and post-intervention design. Nutrition data were collected on a voluntary basis in My Fitness Pal and will be analyzed at a future date.

      Intervention

      The intervention took place over a 12-week period. Of the 12 weekly 90-minute sessions, three were used for social interaction, data collection, and measurements (weeks 1, 6, and 12). The remaining nine sessions were evenly divided into three didactic sessions for each content area: nutritional education, stress management and mindfulness education, and LB- specific health topics. In addition to these nine content sessions, participants had the opportunity for a 1-hour in-person nutrition consultation with a registered dietician to discuss their personally identified goals. All participants were given a 4-month membership at a local gym and a SMART Health Walking Fit timekeeper to encourage physical activity. In addition, participants were encouraged to use the MyFitnessPal calorie counter application to communicate within the group, and to track food consumption and physical activity. The group facilitator encouraged participants to go to the gym after each meeting to work out with other group members for encouragement, social support, and community building. Participants had access to every DC metro-area branch of this gym with 18 locations for four months (including 30 days of access after the intervention). Participants were also directed to a page within the Whitman-Walker website that listed local healthy weight resources as well as health and fitness tools for those seeking to monitor their food intake and exercise activities. Intervention details are provided in Appendix C.

      Unique features

      MOVE was the fourth round of refinement of prior pilot work done by
      • Fogel S.
      • Young L.
      • McPherson J.B.
      The experience of group weight loss efforts among lesbians.
      ,
      • Fogel S.
      • Young L.
      • Dietrich M.
      • Blakemore D.
      Weight loss and related behavior changes among lesbians.
      ,
      • Fogel S.C.
      • Calman L.
      • Magrini D.
      Lesbians' and bisexual women's definition of health.
      to capitalize on the stated needs of the DC metro-area LB population. Participants were given a SMART Health Walking Fit timekeeper to encourage physical activity, although no data were collected from the device. Participants were also encouraged to use the MyFitnessPal application to connect with other group members and track nutrition and physical activity; limited data were collected from this resource. Gym memberships and group gym sessions after each scheduled meeting provided an opportunity for more social bonding and mutual support.

      Challenges

      A challenge for MOVE was recruitment, owing to competing events and programs in the DC metro area. In addition, the location of the group meeting sites significantly influenced recruitment of participants into the study, because travel time was often cited as a consideration in participation.

      Profile 4. SHE (Strong, Healthy, Energized)

      Community partner

      The Lewin Group partnered with SAGE in New York City, a full-time center for LGBT people aged 60 and older that provides a comprehensive array of unique services and programs related to arts and culture, fitness, food and nutrition, health and wellness, and lifelong education.

      Program focus

      SHE was a community-based support group and fitness intervention designed to help participants develop healthier nutritional habits and improve physical fitness through walking. SHE used a pre–post design to evaluate changes in fruit and vegetable consumption, reduction of sugar-sweetened beverage consumption, and average daily steps walked in addition to the secondary objectives.

      Intervention

      The program consisted of a 12-week intervention emphasizing the importance of social interaction among participants. Two groups were convened at SAGE in New York City. Each 90-minute, co-facilitated weekly session consisted of four components:
      • 1.
        A 30-minute exercise (both seated and standing) featuring resistance training using TheraBands (exercise bands) to accommodate varying levels of ability among participants;
      • 2.
        A stress reduction activity;
      • 3.
        Nutrition education explaining the nutritional component and cooking tips for a featured food, along with reasons why it should be incorporated into the diet; and
      • 4.
        An open forum discussion allowing participants to share issues encountered, successes and best practices related to use of the Fitbit, and walking, nutrition, or stress reduction techniques.
      At the beginning of each session, participants reported the number of steps walked that were then compiled into individualized reports. Participants were also given a weekly goal of increasing their daily number of steps by 10% until they reached 10,000 steps. For those who entered the program already walking 10,000 steps and for those who reached 10,000 steps during the program, an emphasis was placed on increasing the amount on a weekly basis. At the end of each session, participants were encouraged to go on a walk together. Additional details are in Appendix D.

      Unique features

      New York City is an urban center with a robust public transportation systems that supports walking as the norm. This type of environment might be optimal for using walking as a tool to improve physical fitness. The Fitbit was a significant element in this study and embraced as a motivational tool. For most participants, it was their first foray into use of an electronic device that provided instant, reliable feedback on their physical activity.
      Also, SAGE, the only full-time municipally funded LGBT senior center in the United States, incorporated the SHE program into its ongoing programs, which fit well into the structure of the center and facilitated recruitment. Because the SAGE Center targets older sexual and gender minority individuals (≥aged 60 years), the recruitment of participants into the SHE program translated into much older participants on average than the other HWLB programs.

      Challenges

      Wave 1 of the project occurred during the winter months with concurrent snow/ice conditions. A number of participants suffered adverse events (including debilitating falls) that limited their ability to engage in the program fully. The prevalence of this occurrence is likely owing to the older age of this group. Participants also faced challenges in accessing the program's technology-based tools and information. Most did not have an iPhone or computer, so the full functionality of the Fitbit was not used. Because participants were unable to follow the directions to register their Fitbits, their data could not be automatically downloaded, so participants had to manually record their steps each night on log sheets. As a pilot project, enrollment into the program was limited to 20 individuals to match the seating capacity of the meeting room at SAGE. Given feedback from participants, additional time or fewer participants for group discussion and interaction may be warranted to ensure that all participants have a chance to participate within the discussion time.

      Profile 5. WHAM (Women's Health and Mindfulness)

      Community partners

      RTI partnered with Lyon Martin Health Services, the first and only community health center in the world established to address barriers to care and improve health outcomes for lesbians. Lyon Martin Health Services provides care to lesbians, women of color, low-income women, older women, women with disabilities, and transgender people.

      Program focus

      Recruiting participants from San Francisco and the East Bay area, WHAM is a clinic-based group education and support program designed to integrate nutrition, physical activity, and mindfulness to address increased risk of chronic illness. A design was used whereby participants were randomized to an immediate or a delayed intervention start, with the delayed start group constituting the comparison group. Biological, behavioral, and psychosocial outcomes were assessed at baseline and post-intervention. The primary outcomes measured at pre- and post-intervention included hemoglobin A1c (average fasting blood glucose), cholesterol, physical activity levels, diet, mindfulness, and mindful eating.
      The intervention was divided into eight groups. Each 12-week session was offered in two locations (San Francisco and Berkeley). Women were randomly assigned to either immediate or delayed start groups at enrollment. Participants chose the location most convenient for them and groups ranged in size from 6 to 14 people. The first two weekly sessions were 3 hours long and sessions 3 through 12 were 2 hours in length. One hour of every session was dedicated to didactic lectures on mindfulness in nutrition, physical activity, stress reduction, and LB age-related topics and the remaining time was for open discussion and mindfulness exercises (
      • Brown K.W.
      • Ryan R.M.
      The benefits of being present: Mindfulness and its role in psychological well-being.
      ,
      • Ludwig D.S.
      • Kabat-Zinn J.
      Mindfulness in medicine.
      ). Near the end of the meeting (in weeks 1, 2, 5, and 12), a personal trainer and a nutritionist met either individually or in small groups with participants for 10- to 15-minute sessions each to review the participants' SMART goals associated with physical activity and nutrition. If time became an issue, telephone consults were provided as needed so that all participants received the individualized consults. Approximately one-half of the participants wore accelerometers for seven days pre- and post-intervention to measure activity levels. Unlike pedometers, which only measure steps, accelerometers measure movement intensity and duration. Accelerometer data were not reported back to participants. Intervention details are provided in Appendix E.

      Unique features

      WHAM strongly relied on principles of community-based participatory research at all levels of the research process, including considering and developing research questions, designing the methodology, participating in the research activity, analyzing the results, and disseminating the findings (
      • George M.A.
      • Daniel M.
      • Green L.W.
      Appraising and funding participatory research in health promotion. 1998-99.
      ,
      • Israel B.A.
      • Schulz A.J.
      • Parker E.A.
      • Becker A.B.
      Review of community-based research: Assessing partnership approaches to improve public health.
      ). The concept of mindfulness guided the core components: nutrition education, physical activity, and stress reduction. Weekly mindfulness homework activities were also encouraged. Like DIFO, the nutrition and physical activity components were based on the tenets of Health At Every Size, which asserts a weight-neutral approach to health with a focus on intuitive eating, enjoyable movement, and the multidimensional nature of health (
      • Bacon L.
      Health at every size: The surprising truth about your weight.
      ).

      Challenges

      WHAM faced challenges in recruitment and engagement of participants. Participant schedules were the main hurdle. Another challenge was obtaining fasting blood samples from participants. Although not a significant obstacle (because blood draws could be done at approved laboratories throughout the city as well as at Lyon Martin Health Services), this component of the study delayed the start date.

      Discussion

      These five HWLB programs represent the first coordinated national initiative to address an important gap in promoting healthy weight and well-being among older LB women. Despite differences in approach, the OWH-required common elements of exercise, social support, and education on nutrition and physical activity were incorporated across program sites. Intervention content was tailored to provide a safe, welcoming environment that addressed the specific information needs identified by the LB women participating in the interventions. Because the centrality of social support is particularly important in promoting a healthy weight for many populations, including LB women (
      • Verheijden M.
      • Bakx J.
      • Van Weel C.
      • Koelen M.
      • Van Staveren W.
      Role of social support in lifestyle-focused weight management interventions.
      ), all HWLB programs incorporated group meetings over a 3- to 4-month period with varying degrees of structured social support to promote community building.
      Although the intervention as a whole was a coordinated effort, each program was tailored locally to the communities served. Existing community norms about weight loss programs varied by geographic location and had to be addressed at a local level. Language about “healthy weight” caused discomfort for some and backlash from others (for whom the fat-positive movement's ideals resonate;
      • Saguy A.C.
      • Ward A.
      Coming out as fat rethinking stigma.
      ). In contrast, some participants in WHAM, SHE, and LOLA proactively requested more accountability and a desire to lose weight during the program.
      Although all HWLB programs addressed the goals of promoting healthier food and beverage choices and incorporating physical activity routines into daily activities, specific intervention approaches differed across HWLB programs. For example, although most interventions incorporated more traditional nutritional information messages, WHAM and DIFO included a mindfulness approach. There were also considerable differences in physical activity components and future analyses will evaluate the effect of these interventions on weight or waist circumference over height. DIFO and SHE included physical activity instruction for women who required assistive devices and DIFO developed a video to encourage physical activity at home. Project LOLA focused on fitness as an outcome and included both fitness and medical (e.g., comprehensive metabolic panel and lipid profiles) measures. SHE provided Fitbits to their older population living in New York City as a motivational tool for increasing the number of steps walked per day. The MOVE, WHAM, LOLA, and SHE intervention programs offered participants access to individual personal training sessions.

      Limitations

      The major limitation in this study was the short intervention period—only 12 or 16 weeks (
      • Wing R.R.
      • Lang W.
      • Wadden T.A.
      • Safford M.
      • Knowler W.C.
      • Bertoni A.G.
      • Wagenknech L.
      Look AHEAD Research Group
      Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes.
      ). Another limitation is that not all sites included follow-up and maintenance and/or comparison or control groups. No medical or psychological exclusions were required. The only psychological measure was the Mental Component Score included in the core survey. In the future, interventions should consider adopting a trauma-informed or other approach to ensure the safety of participants, especially if recruiting people with a history of eating disorders or other mental illness.

      Implications for Practice and/or Policy

      Designing the initiative as a set of interrelated programs has significant advantages in addressing the literature gap about health interventions for older LB women. Core measurements across the HWLB programs allow for pooled analyses. With 376 women at baseline, future subgroup analyses of outcomes can be conducted with sufficient statistical power. Differences in study design allow analysis of specific HWLB program elements, such as focusing on fitness and gym memberships (MOVE and LOLA), providing SMART pedometers (SHE, LOLA, and MOVE), using mindfulness and Health at Every Size (WHAM and DIFO), or providing medical laboratory results (WHAM and LOLA).
      These interventions are a first step in developing models of healthy weight programs for LB women. Using a coordinated approach that uses shared measures and combined results, this project tests multiple intervention approaches with a common goal in a large and geographically diverse sample of LB women. Outcomes of the primary and secondary objectives from this study will be the subject of future papers. Because many health indicators take longer to track and continued support is helpful (

      U.S. Department of Health and Human Services. (2014). managing overweight and obesity in adults: Systematic evidence review from the Obesity Expert Panel. Available: www.nhlbi.nih.gov/health-pro/guidelines/in-develop/obesity-evidence-review/index.htm

      ), future research should include maintenance sessions and follow-up periods for a year or more.
      This initiative fills a major gap identified by two IOM reports: the need for culturally centered approaches for LB women (Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation [2012], and The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding [2011]). The HWLB initiative was the first federal intervention program to address a specific health concern of LB women. Further, the approach recognized that interventions addressing local community norms and needs would be more powerful than one-size-fits-all interventions. The documentation and analysis of the effectiveness of these five diverse projects will provide guidance for model programs and future research on LB populations.

      Acknowledgments

      This publication was made possible by Contract Numbers The CDM Group Inc.: HHSP23320095629WC; George Washington University: HHSP23320095635WC; Lewin Group: HHSP223320095639WC; IMPAQ International (formerly Berkeley Policy Associates): HHSP233420095615; NORC: HHSP23320095647; and Research Triangle Institute: HHSP223320095639WC from the Office on Women's Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Office on Women's Health, the Office of the Assistant Secretary for Health, or the U.S. Department of Health and Human Services.

      Supplementary Data

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      Biography

      Sarah C. Fogel, PhD, is a Professor and Academic Director at Vanderbilt University School of Nursing. Dr. Fogel's research spans information needs of people living with HIV/AIDS, disclosure of sexual identity to healthcare providers, and obesity among lesbian and bisexual women.
      Jane A. McElroy, PhD, is Associate Professor of the University of Missouri, Department of Family & Community Medicine. Dr. McElroy is an epidemiologist focusing on health disparities, which includes sexual and gender minority research and environmental exposure and health risks.
      Samantha Garbers, PhD, is Assistant Professor of Population & Family Health at Columbia University's Mailman School of Public Health. She has more than a decade of experience evaluating interventions to reach women of color and sexual and gender minority populations.
      Cheryl McDonnell, PhD, Senior Analyst at The CDM Group, is an experimental psychologist with more than 30 years of experience in applied research, program evaluation, and management of large-scale, multi-site research in health, substance abuse, and mental health.
      Jacquetta Brooks, MSW, LGSW, holds a master's from Howard University and a bachelor's in psychology from the University of North Carolina, Wilmington. A Community Health Manager at Whitman-Walker Health, she oversees programs focused on cancer and LGBT health disparities.
      Michele J. Eliason, PhD, Professor, Department of Health Education, San Francisco State University, has experience conducting research and teaching about LGBTQ health including identity development, health care provider attitudes, physical health, substance abuse, and mental health aspects of stigma.
      Natalie Ingraham, MPH, is a Project Coordinator at Lyon-Martin Health Services, a Program of HealthRight360 and a doctoral candidate in sociology at UC San Francisco. Her research focuses on medical sociology, embodiment, women's health, and body size.
      Ann Osborn, MBA, is a Vice President in the Lewin Group. Her areas of expertise include government healthcare programs, access to care, managed care, and provider reimbursement and accessibility.
      Nada Rayyes, PhD, evaluates education and community programs. She holds a PhD in Education from the University of California, Santa Barbara. Dr. Rayyes is a Senior Research Associate at IMPAQ, International, LLC, a social policy research firm in Oakland, California.
      Sarah Davis Redman, PhD, MPAff, is a Research Scientist at NORC at the University of Chicago. She has over a decade of experience designing and conducting evaluations on a range of public health topics.
      Susan F. Wood, PhD, is Associate Professor, Health Policy and Management, and Director, Jacobs Institute of Women's Health at George Washington University Milken Institute School of Public Health. Her research focuses on women's health policy, reproductive health, cardiovascular disease, and health reform.
      Suzanne G. Haynes, PhD, is Senior Science Advisor for the DHHS' Office on Women's Health (OWH). Since 1992, she has supported lesbian health researchers through OWH initiatives, the HHS Coordinating Committee on LGBT Issues, and the Lesbian Health Fund Board.