Discussion
obesity, sleep disturbance, mood disorders, trauma, post-traumatic symptoms, diet-related non-communicable diseases, post-traumatic stress symptoms, traumatic, perspiration, depressive, post-traumatic stress disorder, PTSD, malnutrition, depression, posttraumatic stress, diabetes
OBESITY, UNDERNUTRITION, INSULIN RESISTANCE, MALNUTRITION, HEAT, DIABETES
The main findings from this study are that individuals who received the EWS lifestyle intervention successfully increased their brown rice consumption and their moderate-to-vigorous activity. And whereas we previously reported that the intervention improved self-reported sleep quality, here we found that it did not impact objective sleep duration, timing, efficiency or WASO. Across groups, individuals who increased brown rice consumption, increased vigorous activity and decreased total sleep time variability showed improved HbA1c. This is the first randomized trial specifically designed to reduce risk for diabetes in refugees with depression [Healthy nutrition changes are complicated by historical experiences of nutritional hardship. Refugee households may experience nutritional “double burden”. The double burden of malnutrition is characterized by the coexistence of undernutrition along with overweight, obesity or diet-related non-communicable diseases, within individuals, households and populations, and across the life-course [Eating in refugee populations is also influenced by high levels of post-traumatic stress symptoms. Cambodians specifically endured famine and forced starvation at the hands of Khmer Rouge. Starvation is often described as one of the most traumatic aspects of the Pol Pot regime. Deliberate withholding of food and forced communal meals to regulate intake were widespread. Individuals with post-traumatic stress disorder (PTSD) exhibit more emotional eating in response to stressors than those without PTSD [Physical activity is also complicated by a history of trauma. Individuals with symptoms of posttraumatic stress may tend to seek physiological quiescence and avoid physical arousal, including the increased heart rate, respiration, and perspiration caused by physical activity. Cambodians experienced forced labor under the Khmer Rouge, with long hours of inhumane work such as digging ditches and breaking rocks in intense heat. Thus, physical activity may trigger post-traumatic symptoms. We should note that EWS participants were not only willing, but enthusiastic, to join in group exercise as part of the EWS sessions. Actigraphy showed that the physical activity during this structured, supervised, and supportive setting successfully generalized to more moderate-to-vigorous activity in daily life outside of intervention sessions. The effect sizes for increases in physical activity at 12-months were small-to-moderate.Individuals with mood disorders and trauma history often experience sleep disturbance [In exploratory analyses, we examined how changes in health behaviors were associated with changes that we have previously reported in our primary outcomes, i.e., HbA1c, depressive symptoms, and insulin resistance [We were surprised that no health behavior changes were associated with improved depression or change in insulin resistance. We hypothesize that the improvements in depression experienced by the intervention groups, previously reported [