isobel contento, ph.d., cdn department of health and behavior studies teachers college, columbia...
TRANSCRIPT
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Isobel Contento, Ph.D., CDNDepartment of Health and Behavior Studies
Teachers College, Columbia University
National Obesity Prevention Conference, October 27, 2004
How Do We Design Effective, Integrated Nutrition Education
Programs: Research Needs
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Biologically determined behavioral
predispositions:
•Taste/pleasure •Sweet, sour, salt, bitter
•Hunger/satiety mechanisms•Sensory specific satiety
•Brain mechanisms
Experience with food: Associative conditioning
Physiological conditioning:•Familiarity: learned safety
•Conditioned preferences
•Conditioned satiety
Social conditioning:•Models•Rewards•Social affective context
Intra-personal factors:
•Beliefs•Attitudes •Expectancies•Benefits•Barriers•Self-efficacy•Self identity•Moral/ethical•Stage in change process•Knowledge & skills
Environmental factors:
Socialenvironment:•Social networks & relationships•Cultural practices
Physical environment
•Food availability (under & over)•Technology
Informational Environment•Advertising•Education•Media
Interpersonal factors:•Social norms•Cultural norms
FOOD BEHAVIORS
Contento 2000
Economicenvironment•Resources•Price
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Biologically determined behavioral
predispositions:•Taste/pleasure
•Sweet, sour, salt, bitter•Hunger/satiety mechanisms
•Sensory specific satiety•Brain mechanisms
Experience with food: Associative conditioning
Physiological conditioning:•Familiarity: learned safety
•Conditioned preferences
•Conditioned satiety
Social conditioning:•Models•Rewards•Social affective context
Intra-personal factors:
•Beliefs•Attitudes •Expectancies•Benefits•Barriers•Self-efficacy•Self identity•Ethical/moral obligations•Ethnic identities•Stage in change process•Knowledge & skills
Environmental factors:
Socialenvironment:•Social networks & relationships•Cultural practices
Physical environment
•Food availability (under & over)•Technology
Informational Environment•Advertising•Education•Media
Interpersonal factors:•Social norms•Cultural norms
NUTRITIONINTERVENTIONS
Contento, SNE, July 27, 2003
Economicenvironment•Resources•Price/cost
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SOCIAL-ECOLOGICAL MODEL
A theory-based framework to characterize the variety of influences on nutrition and physical activity behaviors and the potential levels of interventions for obesity prevention
Gregson, Forester, Orr, et al., JNE, 2001;33:S4-15McLeroy, Bibeau, Steckler, Glanz. Health Ed Q. 1988;15:351-377
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IndividualBiological givens
Experience with food
Beliefs, attitudes
Knowledge
Interpersonal factors:
Family Peers
Social networks
Institutional/organizational
Social structure
Interventions
Community
Policy
Systems
Local, state,federal
Social networksNorms Standards
Rules, policies,informal networks
Spheres of Influence
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OVERWEIGHT PREVENTION STUDIES
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OVERWEIGHT PREVENTION STUDIES
Study Target Group
Target Behaviors
Intervention Findings
Donnelly, 1996CCT
3-5th graders
n =338
Metabolic fitness via diet and PA
School meals - lower fatNE - 9 sessions/yearPA -- 3x week
At end of yr 2:BMI - nsMetabolic fitness - ns
Flores, 1995RCT
10-13 yrs
AA, Hispanic
n =110
Aerobic exercise Aerobic dance in school PE 3x week, 12 weeks
BMI p<.05 girls
Jeffery & French1997RCT
Community adults
Ages 20-45 y
n =1226
Men & women, hi & low-income
Prevention of wt gain through eating and exercise
1. Education = mthly newsletters + classes 2x/year
2. Education + lottery
3. No-contact control
Weight gain-ns
Diet - ns
PA - ns
Less wt gain in hi income than low income
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OVERWEIGHT PREVENTION STUDIES
Study Target Group
Target Behaviors
Intervention Findings
Gortmaker 1999Cluster RCT
Planet Health
6-8th graders
Mixed ethnicity
(n=1295)
TV /videoHi-fat foodsF&VMVPA
16 lessons each yr/2 years in 4 subject areas PE -- MVPA + 30 5-min lessons for goal-setting
BMI + TSF p<.05 for girls TV *Fat & cals *girlsF&V *girlsPA - ns
Robinson1999Cluster RCT
3-4th graders
Mixed ethnicity
(n=192)
TV/video 18 lessons- 2 mo. TV turnoff for 10 days
TV --> 7 hr/week Home - newsletters
+TV time manager
BMI*, TSF *
TV *
Meals w/TV *
PA -ns
Hi fat foods -ns
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OVERWEIGHT PREVENTION STUDIES
Study Target Group
Target Behaviors
Intervention Findings
Pathways:Caballero2003RCT
3-4th gradersAmerican Indian
Az, NM & SD(n=1704)
Healthful foods(lo fat and hi F&V)
PA
Foods served: lower fat PE - 30 min 3/wk MVPA(SPARK) Classroom: 45 min 2xwk,12 weeks in grades 3&4; 8 weeks in grade 5. Family nights, home action packs
% body fat - nsBMI - ns% fat in school lunch*24-hr recalls: calorie intake*% fat*Accelerometer- nsPA Quest - ns
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OVERWEIGHT PREVENTION STUDIES
Study
(pilot)
Target Group
Target Behaviors
Intervention Findings
Neumark-Sztainer2003
New Moves
9-10th grade
girls(n=201)
Mixed ethnicity
PA
Eating patterns
_____________
Self-perceptions
Social support
PE alternative class for credit
5/wk, 16 weeks
______________
PA 4x/wk
Social support 1x /2 wks
Nutr. guidance 1x /2 wks
BMI -ns
Self-perceptions -ns
PA - ns
Eating patterns - ns
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OVERWEIGHT PREVENTION STUDIES
Study(pilots)
Target Group
Target Behaviors
Intervention Findings
GEMSStanford, CA2003
8-10 yr old AA girls +Families(n=61)
PA
TV/video
After school dance class in community centers - 12 weeks 5 lessons in the home to reduce TV
BMI, waist - trSelf TV - trFamily TV* Dinners w/TV*Concern weight*
GEMS Minnesota2003
8-10 yr old
AA girls + families
(n=54)
PA
Healthy eating
After school PA + healthy eating 2/wk, 12 weeks
BMI - ns
PA - tr
Diet - tr
Pycho-social - tr
Girls health Enrichment Multi-site Studies
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OVERWEIGHT PREVENTION STUDIES
Study(pilots)
Target Group
Target Behaviors
Intervention Findings
GEMSBaylor, TX2003
8-10 yr old AA girls +Families(n=35)
FJV
PA
4-week summer 8-week home Internet
BMI -tr
Other measures -tr
GEMSTennessee2003
8-10 yr old
AA girls +
families
(n=60)
Sweetened beverages
Water
PA
Child weekly sessions Parent sessions
12 weeks
BMI, waist -tr
Sweet bev. - 34%
Water - 1.5%
MVPA - 12%
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation issues
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets:Eating Patterns: Increase F & V; healthy eating; water Decrease: low-fat foods; sweetened sodas
Physical Activity: Increase MVPA; Decrease TV/ video
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targetsEating Patterns: Increase F & V; healthy eating; water Decrease: low-fat foods; sweetened sodas
Physical Activity: Increase MVPA; Decrease sedentary behavior: TV/ video
Weight as outcome?
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets Eating Patterns: Increase F & V; healthy eating; water Decrease: low-fat foods; sweetened sodas
Physical Activity: Increase MVPA; Decrease sedentary behavior: TV/ video
Eat less
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets Eating Patterns: Increase F & V; healthy eating; water Decrease: low-fat foods; sweetened sodas
Physical Activity: Increase MVPA; Decrease sedentary behavior: TV/ video
Eat less: conscious/ competent eating
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DESIGNING PROGRAMS: RESEARCH NEEDS
Theory: Specifies relations among variables in order to explain and predict events (e.g. food or PA behaviors):
Biological }Psychosocial } variables Diet and PA behaviorsBehavioral } (predict)Environmental}
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DESIGNING PROGRAMS: RESEARCH NEEDS
Theory:
Nutrition/ ---> change in predictors --> change in PA of behaviors behaviors interventions specified by theory
(mediating variables)
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DESIGNING PROGRAMS: RESEARCH NEEDS
Theory: Predictiveness of most current theories or models have been modest (r2 < 0.3) Need to explore more relevant/ additional mediating variables Theory that takes into account the complexities of food choice Theory that helps us understand how individuals and the environment interact. Qualitative studies/grounded theory Best practices/field studies to inform theory development
Baranowski et al. Ann Rev Nutr 1999;19:17-40Baranowski et al. Am J Prev Med 1998;15:266-297Baranowski et al. Obesity Res 2003;11:23S-43
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DESIGNING PROGRAMS: RESEARCH NEEDS
Intervention Strategies and Implementation Duration and intensity
Fidelity to intervention as designed
Strategies Individual versus environmental Eating patterns versus PA Scaling up from micro-level to community level
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DESIGNING PROGRAMS: RESEARCH NEEDS
Intervention Strategies and Implementation
Strategies Settings Research with large sample of those who have managed to remain at a healthy weight Carefully documenting school & community programs e.g. farm to school programs; school meal changes
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DESIGNING PROGRAMS: RESEARCH NEEDS
Carefully documenting school & community programs
Shaping America’s Youth: Survey (September 2004) 1500 organizations sent survey: might fund or conduct programs addressing “physical activity and excess weight in childhood”: 1200 responded
1831 active programs: 240 childhood overweight intervention; 369 prevention;
242 prevention all ages; 621 general health/fitness, 120 research; 205 other. 2004 expenditures = $3.9 billion (low estimate) to $7 billion (mid estimate) Therefore: many programs already operating. Careful evaluation and documentation would move the field forward.
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DESIGNING PROGRAMS: RESEARCH NEEDS
Evaluation and measurement issues Standardized instruments: individualized interventions Measures : reliability and validity & how administered Instruments: Research vs practice settings Studies: Cross-sectional and/or short term Food choice & PA behaviors are very complex: Measuring choices and trade-offs
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DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation and Measurement issues
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IndividualBiological givens
Experience with food
Beliefs, attitudes
Knowledge
Interpersonal factors:
Family Peers
Social networks
Institutional/organizational
Social structure
Interventions
Community
Policy
Systems
Community programsBike-paths
School meals Physical educationWorksites
Leverage points
Food system