isobel contento, ph.d., cdn department of health and behavior studies teachers college, columbia...
TRANSCRIPT
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
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
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
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
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
OVERWEIGHT PREVENTION STUDIES
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
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
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
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
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
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%
DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation issues
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
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?
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
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
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}
DESIGNING PROGRAMS: RESEARCH NEEDS
Theory:
Nutrition/ ---> change in predictors --> change in PA of behaviors behaviors interventions specified by theory
(mediating variables)
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
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
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
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.
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
DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation and Measurement issues
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