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Behavioral Intervention Strategies to Reduce Childhood Obesity Risk
September 21, 2012 Obesity & Nutrition in a Changing World Symposium CSU, Fullerton Mical Kay Shilts, PhD Associate Professor CSU, Sacramento
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Overview • Review key strategies implemented in a pediatric
obesity prevention intervention – Targeting ethnically diverse, low-income parents of preschool
age children
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Key Strategies • Define behaviors to target • Establish theoretical framework • Identify intervention components • Tailor education materials • Pilot test and evaluate effectiveness with target
audience
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Student Learning Outcomes • The learner will be able to identify key behaviors
related to pediatric overweight
• The leaner will be able to understand how Social Cognitive and Goal Setting theories can be applied in a community setting
• The learner will be able to provide examples of how to tailor education materials to low-income, low-literate audiences
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Activity • Select a behavior you have attempted to
change (successful or not) – What skills & resources did you need to make the
change? – What got in the way of change (barriers)? – What supported your change? – Were you able to maintain change?
• Why or why not?
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Define behaviors to target
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Literature review identified12 Determinants & 23 behaviors related to pediatric obesity
Determinants Behaviors
Ontai L, Ritchie L, Williams ST, Young T, Townsend MS. Guiding family-based obesity prevention efforts in low-income children in the United States: Part 1− What determinants do we target? Intl J Child Adoles Health. 2009; Vol 2 (1): 19-30. Townsend MS, Young T, Ontai L, Ritchie L, Williams ST. Guiding family-based obesity prevention efforts in low-income children in the United States: Part 2 −What behaviors do we measure? Intl J Child Adoles Health. 2009; Vol 2 (1): 31-48.
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Childhood Obesity Risk Assessment Tools
• Focuses on eating, physical activity, screen time & sleep
Content, face and factor validity established.
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Childhood Obesity Risk Assessment Tools
Parenting- Focuses on child feeding practices Content, face and factor validity established.
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Example of how identified behaviors were integrated into the intervention
• Behavior – Model behavior
• Sample risk assessment questions – My child sits and eats with an adult. – I play outside with my child___days a week. – My child sees me eat vegetables.
• Sample intervention component
– Goal options: Play outside with your child 3 days this week or Sit and eat a meal with your child 3 times this week.
– Each lesson incorporated physically active games that the parent could do with their child
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Example of how identified behaviors were integrated into the intervention
• Behavior – Plan meals
• Sample risk assessment question – I plan meals.
• Sample intervention component – Goal options: Use your favorite recipe
book to plan 2 meals this week. – Participants practice planning a meal
according to MyPlate guidelines and using a weekly grocery ad flyer.
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Establish theoretical framework
1. Social Cognitive Theory 2. Goal Setting Theory
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How can a Theory Help Make Behavioral Interventions More Effective?
• Research has shown that nutrition interventions based on an appropriate behavioral theory are better at promoting behavior change.
• Theories can explain behavior and suggest strategies to achieve behavior change.
Glanz K, Rimer BK. 2005. Theory at a Glance: A Guide to Health Promotion Practice. Bethesda MD: National Cancer Institute. 2nd edition. NIH Publ. 05-3896
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Social Cognitive Theory • Behavior changes result from interaction
between the – personal factors (cognitions), – behavior and – environment (family, friends, peers, coworkers,
physical environment, too);
• Application: Involve the individual and relevant others; work to change the environment.
• The strength of this model is that it focuses on certain target behaviors rather than on knowledge.
Personal factors
Environmental influences
Behavior
Change is bidirectional -Reciprocal Determinism
Bandura A. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs NJ: Prentice-Hall
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Selected Constructs/Strategies of SCT
• Outcome Expectations • Self-efficacy
– Skills mastery – Social support
• Self-regulation – Self-monitoring – Goal setting – Contracting – Barrier counseling – Reinforcement
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Examples of how SCT was applied to our obesity prevention intervention
• Self efficacy- task specific confidence – Practice playing active games
(balloon toss, musical chairs) – Recipe preparation and tasting – Label reading – Meal planning
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Examples of how SCT was applied to our obesity prevention intervention
• Self-monitoring- Use of a technique such as a food record to promote awareness of one’s dietary actions – Healthy Kids obesity risk
assessment tools used to identify strengths and weaknesses
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SCT Components • Barriers-Something that
would prevent an individual from a desired behavior – Barrier discussion and
activity
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Examples of how SCT was applied to our obesity prevention intervention
• Reinforcement - response to a behavior that increase the likelihood of reoccurrence – Reward goal achievement
activity
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Establish theoretical framework
1. Social Cognitive Theory 2. Goal Setting Theory
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What is goal setting?
• Strategy for organizing information and skills into manageable steps.
• Goal setting can elicit motivation, effort, persistence & concentration
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Goal Setting Theory • Effective goals are
– Specific – Proximal – Challenging – Attainable
• Tracking goal progress, focusing on accomplishments = increased confidence Locke, E. A., & Latham, G. P. (2002). Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist, 57, 705-717.
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Goal Setting Framework
Shilts MK, Horowitz M, Townsend MS. 2004. Goal setting as a strategy for dietary and physical activity behavior change: a review of the literature. Am J Health Promot, Nov-Dec;19(2):81-93.
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Goal Setting Theory • Types
Self-set; Participatory; Assigned • Designed new type to meet developmental
needs of adolescents for autonomy…Guided • Reduces inappropriate goal selection;
– goal choices have attributes for optimal effectiveness …specificity, proximity, difficulty, attainability.
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Low-income parents…
Adapted our intervention work on guided goal setting as a behavioral strategy
Shilts M, Horowitz M, Townsend MS. An Innovative Approach to Goal Setting for Adolescents: Guided Goal Setting. J Nutr Educ Behav. 2004; 36:155-156.
Shilts M, Horowitz M, Townsend MS. Goal Setting as a Strategy for Dietary and Physical Activity Behavior Change: A Review of the Literature. Am J Health Promo 2004; 19:81-93.
Shilts MK, Horowitz M, Townsend MS. Effectiveness of guided goal setting in a dietary and physical activity intervention with low-income adolescents. Int J Adolesc Med Health: 2009; 20(1):111-122.
Adolescents
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Goals are customized to parent
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Goal Setting • Contract • Tracking
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Tailor education materials
Assessment tools Guided Goal Setting
My Healthy Plate
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Assessment tools • Many of the survey photos were taken with client ’s
permission in their homes and using their children as models.
• Survey photos represent the target audience
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Assessment tools • To meet the needs of low-
literate parents – Parent feedback was used to
simplify text and develop content relevant photographs.
– Increased font size – Short sentences – Limited multi-syllable words – Pictures added
• Readability 1.3
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Guided Goal Setting • Tailored to parent motivators for goal
attainment – Children – Health
• Parents indicated goal content should
focus on their child, meal planning and shopping – Plan and prepare 3 meals at home this
week instead of eating out. – Have your child help choose fruit and
vegetables at your next shopping trip.
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Guided Goal Setting
• Magazine style workbook – Parents indicated
wanting flexibility in goal selection
– Photographs – Reading level 3.8
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Dietary Guidelines applied to a concrete visual
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Key Messages for My Healthy Plate
• Aim for half of your plate to be fruits and vegetables.
• Aim for one quarter of your plate to be whole grains.
• Aim for one quarter of your plate to be meat and beans.
• Use a 9-inch plate.
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Hands-on activity: Make your own My Healthy Plate
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My Healthy Plate • Tailored for low-income parents of young
children – Visual alone was not effective – Photographs of commonly consumed foods were
taken
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My Healthy Plate • Commonly eaten foods were
identified from a review of EFNEP participant 24-hour recalls (n=165).
• Depicted foods were adjusted based on feedback from low-income adults (n=227) participating in WIC.
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My Healthy Plate • Messages and visuals tailored to target audience
preferences – In-depth interviews were conducted (n=64) regarding
preferences for messages to accompany Plate photos
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My Healthy Plate • To facilitate behavior
change at home a handout and goal setting sheet were developed
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My Healthy Plate • Activities tailored to
target audience – Child-centered activity to
practice concepts covered during intervention
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Pilot test and evaluate effectiveness with target audience
Guided Goal Setting My Healthy Plate
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Guided Goal Setting • Post intervention, parents
(n=20) provided feedback in 1-hr individual interviews: – Parents reported that the
personalized goal setting gave them ideas to work on that they “never really thought of” and that it gave them “a wake up call”.
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Guided Goal Setting • Parents reported a high
level of goal effort (91%) and goal achievement (78%).
• Parents reported preference for goal personalization & goal options.
• The goal contract and weekly goal tracking were least motivating.
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My Healthy Plate • Evaluated feasibility of integrating My Healthy Plate
(MHP) concepts into a childhood obesity prevention intervention. – Parents (n=20) participated in in-depth interviews.
• Participants were able to recall major MHP themes, “Less meat, more vegetables”.
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My Healthy Plate • Parents reported that the
MHP visuals/photos gave them ideas of what to serve : – “Before with pizza, I just
gave pizza as a meal, but now I put other things with it like fruit or carrots. I got the idea from the pictures in class”
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My Healthy Plate • Challenges were applying MHP
when eating away from home and serving fruit on the same plate as a warm or savory dish.
• Parents suggested that additional educational materials would be helpful: – MHP refrigerator magnet – shopping list pad – text message reminders
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Review Student Learning Outcomes
• The learner will be able to identify key behaviors related to pediatric overweight
• The leaner will be able to understand how Social Cognitive and Goal Setting theories can be applied in a community setting
• The learner will be able to provide examples of how to tailor education materials to low-income, low-literate audiences
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Credits • Funding
– USDA NIFA 2010-85215-20658 – USDA NRI 2009-55215-05019
• Collaborators – Marilyn Townsend, PhD, RD-UC Davis – Lenna Ontai, PhD-UC Davis – Stephanie Stinick, PhD-University of Pittsburgh – Kathryn Slyva, MFA-UC Davis – Cathi Lamp, MS, MPH, RD-UCCE – Margaret Johns, MPA, RD-UCCE – Connie Schneider, PhD, RD-UCCE – Lindsay Allen-PhD-USDA WHNRC – Dennis Styne, MD-UC Davis Medical Center – Christine Davidson-UC Davis – Larissa Leavens-UC Davis