{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,25]],"date-time":"2026-02-25T20:42:00Z","timestamp":1772052120248,"version":"3.50.1"},"reference-count":41,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2024,12,17]],"date-time":"2024-12-17T00:00:00Z","timestamp":1734393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Institutes of Health, National Heart, Lung and Blood Institute","award":["R01 HL120702"],"award-info":[{"award-number":["R01 HL120702"]}]},{"name":"National Institutes of Health, National Heart, Lung and Blood Institute","award":["1013938"],"award-info":[{"award-number":["1013938"]}]},{"name":"U.S. Department of Agriculture, National Institute of Food and Agriculture","award":["R01 HL120702"],"award-info":[{"award-number":["R01 HL120702"]}]},{"name":"U.S. Department of Agriculture, National Institute of Food and Agriculture","award":["1013938"],"award-info":[{"award-number":["1013938"]}]}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Multilevel interventions have demonstrated efficacy in improving obesity and other related health outcomes. However, heterogeneity in individual responses indicates the need to identify the factors associated with responses and non-responses to multilevel interventions. The objective of this report is to identify the potential sources of heterogeneity through the exploration of the moderation effects of participant characteristics (sociodemographic and baseline physical\/mental health) in the Strong Hearts, Healthy Communities-2.0 (SHHC-2.0) intervention. Methods: SHHC-2.0 is a 24-week multilevel intervention to improve people\u2019s diet and physical activity evaluated using a cluster-randomized, controlled trial design conducted with women aged 40 and older living in rural communities with an elevated risk of cardiovascular disease, defined as having a BMI &gt; 30, or a BMI 25\u201330 plus &lt; 1 weekly occurrence of 30 min of physical activity during leisure time. Linear mixed models were used to compare the between-group changes in the outcomes (weight, systolic blood pressure, hemoglobin A1c [HbA1c], and triglycerides), with an interaction term included for each potential moderator. Results: Within the sociodemographic characteristics, there were no differences in effectiveness by age, income, or baseline BMI status, however the participants with a high school education or less experienced greater weight loss. Among their health history, only a history of hypertension was associated with differential outcomes; those with a history of hypertension demonstrated a greater reduction in systolic blood pressure. The participants with elevated depressive symptoms demonstrated greater weight loss and a greater reduction in the HbA1c level. Conclusions: SHHC-2.0 was effective across a wide range of participants. The identified moderators (i.e., education level) may inform the future tailoring of the SHHC intervention to optimize the outcomes among participant subgroups, while more broadly, our findings can serve to inform the development and dissemination of multilevel interventions.<\/jats:p>","DOI":"10.3390\/nu16244353","type":"journal-article","created":{"date-parts":[[2024,12,17]],"date-time":"2024-12-17T10:54:02Z","timestamp":1734432842000},"page":"4353","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Heterogeneity in Health Outcomes in the Strong Hearts, Healthy Communities-2.0 Multilevel Intervention in a Community-Randomized Trial: An Exploratory Study of Moderators"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8168-2829","authenticated-orcid":false,"given":"Chad","family":"Rethorst","sequence":"first","affiliation":[{"name":"Institute for Advancing Health Through Agriculture, Texas A&M University, Dallas, TX 75252, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Margaret","family":"Demment","sequence":"additional","affiliation":[{"name":"Institute for Advancing Health Through Agriculture, Texas A&M University, Dallas, TX 75252, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7460-9447","authenticated-orcid":false,"given":"Seungyeon","family":"Ha","sequence":"additional","affiliation":[{"name":"Statistical Consultation Center, Texas A&M University, College Station, TX 77843, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4366-5622","authenticated-orcid":false,"given":"Sara","family":"Folta","sequence":"additional","affiliation":[{"name":"Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8989-1417","authenticated-orcid":false,"given":"Meredith","family":"Graham","sequence":"additional","affiliation":[{"name":"Institute for Advancing Health Through Agriculture, Texas A&M University, Dallas, TX 75252, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Galen","family":"Eldridge","sequence":"additional","affiliation":[{"name":"Institute for Advancing Health Through Agriculture, Texas A&M University, Dallas, TX 75252, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5115-2341","authenticated-orcid":false,"given":"Rebecca","family":"Seguin-Fowler","sequence":"additional","affiliation":[{"name":"Institute for Advancing Health Through Agriculture, Texas A&M University, College Station, TX 77840, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2042018820934955","DOI":"10.1177\/2042018820934955","article-title":"Adult obesity complications: Challenges and clinical impact","volume":"11","author":"Ansari","year":"2020","journal-title":"Ther. Adv. Endocrinol. Metab."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1111\/cob.12203","article-title":"A systematic review of reviews: Exploring the relationship between obesity, weight loss and health-related quality of life","volume":"7","author":"Kolotkin","year":"2017","journal-title":"Clin. Obes."},{"key":"ref_3","first-page":"354","article-title":"Direct medical costs of obesity in the United States and the most populous states","volume":"27","author":"Cawley","year":"2021","journal-title":"J. Manag. Care Spec. Pharm."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1037\/amp0000517","article-title":"Lifestyle modification approaches for the treatment of obesity in adults","volume":"75","author":"Wadden","year":"2020","journal-title":"Am. Psychol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2000","DOI":"10.1001\/jama.2023.19897","article-title":"Obesity management in adults: A review","volume":"330","author":"Schwartz","year":"2023","journal-title":"JAMA"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1146\/annurev-nutr-122123-020340","article-title":"Multilevel interventions targeting obesity: State of the science and future directions","volume":"44","author":"Graham","year":"2024","journal-title":"Annu. Rev. Nutr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e13635","DOI":"10.1111\/obr.13635","article-title":"Design, analysis, and interpretation of treatment response heterogeneity in personalized nutrition and obesity treatment research","volume":"24","author":"Zoh","year":"2023","journal-title":"Obes. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1159\/000351738","article-title":"Estimating the range of obesity treatment response variability in humans: Methods and illustrations","volume":"75","author":"Kaiser","year":"2013","journal-title":"Hum. Hered."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"154388","DOI":"10.1016\/j.metabol.2020.154388","article-title":"Factors affecting weight loss variability in obesity","volume":"113","author":"Dent","year":"2020","journal-title":"Metabolism"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1001\/archpsyc.59.10.877","article-title":"Mediators and moderators of treatment effects in randomized clinical trials","volume":"59","author":"Kraemer","year":"2002","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.amepre.2020.01.027","article-title":"The Strong Hearts, Healthy Communities Program 2.0: An RCT examining effects on Simple 7","volume":"59","author":"Strogatz","year":"2020","journal-title":"Am. J. Prev. Med."},{"key":"ref_12","first-page":"e009333","article-title":"Improvements and maintenance of clinical and functional measures among rural women: Strong Hearts, Healthy Communities-2.0 cluster randomized trial","volume":"15","author":"Eldridge","year":"2022","journal-title":"Circ. Cardiovasc. Qual. Outcomes"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1186\/s12966-022-01401-1","article-title":"Changes in physical activity outcomes in the Strong Hearts, Healthy Communities (SHHC-2.0) community-based randomized trial","volume":"19","author":"Maddock","year":"2022","journal-title":"Int. J. Behav. Nutr. Phys. Act."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1016\/j.ajcnut.2023.09.003","article-title":"Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0","volume":"118","author":"Uribe","year":"2023","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1097\/00005650-199206000-00002","article-title":"The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection","volume":"30","author":"Ware","year":"1992","journal-title":"Med. Care"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A brief measure for assessing generalized anxiety disorder: The GAD-7","volume":"166","author":"Spitzer","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1080\/10705500802222972","article-title":"The Brief Resilience Scale: Assessing the ability to bounce back","volume":"15","author":"Smith","year":"2008","journal-title":"Int. J. Behav. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"385","DOI":"10.2307\/2136404","article-title":"A global measure of perceived stress","volume":"24","author":"Cohen","year":"1983","journal-title":"J. Health Soc. Behav."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1001\/jama.282.18.1737","article-title":"Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire","volume":"282","author":"Spitzer","year":"1999","journal-title":"JAMA"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1111\/1440-1681.12754","article-title":"On the use of one-sided statistical tests in biomedical research","volume":"45","author":"Murphy","year":"2018","journal-title":"Clin. Exp. Pharmacol. Physiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1001\/archgenpsychiatry.2010.2","article-title":"Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies","volume":"67","author":"Luppino","year":"2010","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1159\/000226278","article-title":"Depression and anxiety: Their predictive function for weight loss in obese individuals","volume":"2","author":"Legenbauer","year":"2009","journal-title":"Obes. Facts"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1007\/s13142-016-0452-2","article-title":"Lower depression scores associated with greater weight loss among rural black women in a behavioral weight loss program","volume":"7","author":"Carson","year":"2017","journal-title":"Transl. Behav. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1016\/j.jneb.2009.08.006","article-title":"Low social support level is associated with non-adherence to diet at 1 year in the Family Intervention Trial for Heart Health (FIT Heart)","volume":"42","author":"Aggarwal","year":"2010","journal-title":"J. Nutr. Educ. Behav."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1007\/s12160-015-9716-1","article-title":"Baseline depressive symptoms, completion of study assessments, and behavior change in a long-term dietary intervention among breast cancer survivors","volume":"49","author":"Wang","year":"2015","journal-title":"Ann. Behav. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2156","DOI":"10.1177\/1359105315572451","article-title":"Predictors of adherence in a prevention program for patients with metabolic syndrome","volume":"21","author":"Susin","year":"2016","journal-title":"J. Health Psychol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1038\/sj.ijo.0802727","article-title":"Pretreatment predictors of attrition and successful weight management in women","volume":"28","author":"Teixeira","year":"2004","journal-title":"Int. J. Obes."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"165","DOI":"10.2147\/PPA.S28022","article-title":"Psychological and sociodemographic predictors of premature discontinuation of a 1-year multimodal outpatient weight-reduction program: An attrition analysis","volume":"6","author":"Ahnis","year":"2012","journal-title":"Patient Prefer. Adherence"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Patsalos, O., Keeler, J., Schmidt, U., Penninx, B.W., Young, A.H., and Himmerich, H. (2021). Diet, obesity, and depression: A systematic review. J. Pers. Med., 11.","DOI":"10.3390\/jpm11030176"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1679","DOI":"10.1111\/obr.12752","article-title":"A systematic review and meta-analysis of lifestyle interventions in women of reproductive age with overweight or obesity: The effects on symptoms of depression and anxiety","volume":"19","author":"Wekker","year":"2018","journal-title":"Obes. Rev."},{"key":"ref_31","first-page":"e25651","article-title":"Prevalence and outcomes of depression after bariatric surgery: A systematic review and meta-analysis","volume":"14","author":"Alyahya","year":"2022","journal-title":"Cureus"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1097\/PSY.0000000000000673","article-title":"The effects of dietary improvement on symptoms of depression and anxiety: A meta-analysis of randomized controlled trials","volume":"81","author":"Firth","year":"2019","journal-title":"Psychosom. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.1136\/bjsports-2022-106282","article-title":"Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression","volume":"57","author":"Heissel","year":"2023","journal-title":"Br. J. Sports Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e13438","DOI":"10.1111\/obr.13438","article-title":"A systematic review of inequalities in the uptake of, adherence to, and effectiveness of behavioral weight management interventions in adults","volume":"23","author":"Birch","year":"2022","journal-title":"Obes. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Koch, F., Hoffmann, I., and Claupein, E. (2021). Types of nutrition knowledge, their socio-demographic determinants and their association with food consumption: Results of the NEMONIT study. Front. Nutr., 8.","DOI":"10.3389\/fnut.2021.630014"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1093\/her\/15.2.163","article-title":"Demographic variation in nutrition knowledge in England","volume":"15","author":"Parmenter","year":"2000","journal-title":"Health Educ. Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.1017\/S0007114514000087","article-title":"Relationship between nutrition knowledge and dietary intake","volume":"111","author":"Spronk","year":"2014","journal-title":"Br. J. Nutr."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Seguin, R.A., Eldridge, G., Graham, M.L., Folta, S.C., Nelson, M.E., and Strogatz, D. (2016). Strong Hearts, Healthy Communities: A rural community-based cardiovascular disease prevention program. BMC Public Health, 16.","DOI":"10.1186\/s12889-016-2751-4"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1016\/j.jneb.2018.10.011","article-title":"Process evaluation of Strong Hearts, Healthy Communities: A rural community-based cardiovascular disease prevention program","volume":"51","author":"Sriram","year":"2019","journal-title":"J. Nutr. Educ. Behav."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1186\/s12966-024-01670-y","article-title":"Process evaluation findings from Strong Hearts, Healthy Communities 2.0: A cardiovascular disease prevention intervention for rural women","volume":"21","author":"Szeszulski","year":"2024","journal-title":"Int. J. Behav. Nutr. Phys. Act."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Wang, H., Kenkel, D., Graham, M.L., Paul, L.C., Folta, S.C., Nelson, M.E., Strogatz, D., and Seguin, R.A. (2019). Cost-effectiveness of a community-based cardiovascular disease prevention intervention in medically underserved rural areas. BMC Health Serv. Res., 19.","DOI":"10.1186\/s12913-019-4117-y"}],"updated-by":[{"DOI":"10.3390\/nu18050728","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2024,12,17]],"date-time":"2024-12-17T00:00:00Z","timestamp":1734393600000}}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/16\/24\/4353\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,25]],"date-time":"2026-02-25T09:09:15Z","timestamp":1772010555000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/16\/24\/4353"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,17]]},"references-count":41,"journal-issue":{"issue":"24","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["nu16244353"],"URL":"https:\/\/doi.org\/10.3390\/nu16244353","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,17]]}}}