usda/nopc 2004 individual changes from intervention: how much can we expect? tom baranowski, ph.d....

USDA/NOPC USDA/NOPC 20042004

Individual Changes from Intervention: How Much Can We

Expect?

Tom Baranowski, Ph.D.Professor of Pediatrics (Behavioral Nutrition)

USDA/ARS - Children’s Nutrition Research CenterBaylor College of Medicine

Houston, TX


Save the Best for Last?

Antagonize the Fewest People Since Most People

Have Already Left?

OR


Effect Sizes

Objectives:

– Review school based interventions

– Provide critique of literature


Inclusionary Criteria

To enhance confidence in estimates:

– School as unit

– Adequate power

To assess interesting possibilities:

– Environment vs. curriculum

– Innovation


Studies Included

Elementary Schools:• CATCH• Eat Well & Keep

Moving• High 5 Alabama• Pathways• Bienestar• Cafeteria Power Plus

Middle Schools:• Planet Health• MSPAN• FV Make the Marks


Effect Sizes - Body Composition/Obesity

CATCH Luepker et al 1996

US Elementary Schools n=3959

BMI change

Trt +2.1 ns

Ctl +2.1 ns

Pathways Lohman et al 2003

US Native American Elementary Schools n=1367

% body fat

Study equation

BMI equation

BIA equation

Trt 39.8 ns

40.5ns

40.0 ns

Ctl 39.9 41.0 4.05



Bienestar Trevino et al 2004


% body fat - Crude change

Trt -1.10 ns

Ctl -0.71



Planet Health Gormaker et al, 1999

US Middle Schools n=1295

Girls Boys

Prevalence % Change

Trt -3.3% p=0.03 -1.5% ns

Ctl +2.2% -2.3%

Incidence % Change

Trt +5.5% ns +7.7% ns

Ctl +8.0% +9.6%

Remission % Change

Trt -31.5% p=0.04 -23.7% ns

Ctl -19.1% -26.5%



MSPAN Sallis et al 2003

US Middle Schools n=25,000

BMI Boys Girls

Trt 19.8 ns 19.9 ns

Ctl 20.0 19.7


Effect Sizes - Total Energy Intake

Eat Well & Keep Moving Gortmaker et al 1999


kJ/day adjusted (from 2 24-hdr)

Trt 8473 ns

Ctl 8690



MJ/day change

Trt +0.1 p=0.01

Ctl +0.6



High 5 Alabama Reynolds et al 2000


kcal/day

Follow Up 1 Follow Up 2

Trt 1521 ns 1598 ns

Ctl 1566 1570



Pathways Himes et al 2003


kcal/day at school lunch

Trt -17 ns

Ctl -70kcal/day all day

Ctl - Trt -263 p<0.01kcal/day outside school

Ctl - Trt -195 p<0.01



Planet Health Gortmaker et al 1999


J/day Boys Girls

Trt +630 p=0.05 +453 ns

Ctl +886 +701


Effect Sizes - F&V Servings per Day



# servings per 4184J

Trt 1.78 p=0.01

Ctl 1.41



High 5 Alabama Reynolds et al 2000


24 hr recalls

Follow Up 1 Follow Up 2

Trt 3.96 p=0.0001 3.20 p=0.0001

Ctl 2.23 2.21Cafeteria observation

Trt .38 ns .29 ns

Ctl .38 .38



Cafeteria Power Plus Perry et al 2004


lunch portions/school day from observation

FV F F, no J

Trt 1.3

ns

0.8

p<0.01

0.4

p<0.00

Ctrl 1.2 0.6

(staff verbal encouragements key)





Boys Girls

Trt +0.2 p=0.03 -0.2 ns

Ctl -0.2 -0.5



FV Make the Marks Bere et al in press

Norway Middle Schools n=972

# portions/day FV F

Trt 1 free F 2.4 p=0.06

1.8 p=0.002

Trt 1 encouraged F

2.2 1.5

Ctl 2.0 1.3


Effect Sizes - MVPA



KJ/kg/h from observation of PE

Baseline

4th semester

6th semester

Trt 19.1 21.0

p<0.01

20.8

ns

Ctl 18.6 19.1 19.6


Effect Sizes - MVPA



h/day

Trt +1.21 ns

Ctl +1.36

Pathways Himes et al 2003


Average vector magnitude

24 hr-crude change

Trt +267 ns

Ctl +247(extensive analyses)


Effect Sizes - MVPA



MV Kcal/day at school change scores

Boys Girls

PE Out of PE PE Out of PE

Trt +18.8 +22.3 p<0.00

+12.3 +6.5 ns

Ctl +11.5 +0.2 +7.4 +4.7



H/day Boys Girls

Trt +.011 ns -0.10 ns

Ctl +0.07 -0.03


Effect Sizes - Sedentary Behaviors



TV/Video, h/day

Trt 3.48 p=0.06

Ctl 4.03


Effect Sizes - Sedentary Behaviors



TV Watching. h/day-crude changes

Girls Boys

Trt -0.70 p=0.001 -0.70 p=0.003

Ctl -0.11 -0.35



Sedentary hrs/day

Boys Girls

Trt 4.4 ns 4.6 ns

Ctl 3.9 4.6


Overview of Effect Sizes

• Changes in adiposity and related behaviors have been found– But not always– Sometimes moderated effects

• Changes tend to be small in absolute amounts– But one economic analysis suggests even

small changes can be cost effective



• Desired changes tend to occur in treatment & control groups

– Minimizing differences

• Not sure want decreases in kcal

– But qualitative changes (more likely to get)



• Reported in original units, not in SD units

– Error will vary across studies• Reflected in SD

• Compensation of effects outside of school?


Hard to Compare

• Different interventions• Different measures• Different methods• Controlled for different variables• Reported results in different ways• Logically inconsistent across variables within

studies• Inconsistent findings across studies


Mediating Variable Model (Conceptual)

Intervention Design

Implementation

Mediating Variables

Outcomes

Moderating Variables

Rewards?


(see Baranowski, et al, 2003 Obesity Research)

Mediating Variable Model (2)


Mediating Variable Model (3)

A model for program planning and outcome analysis

School physical education (PE) = curriculum = teacher training

School food service (SFS) = program = staff training

Social marketing campaign = school-based PE and SFS = family based = student based

School supported individualbehavioral change = SBIR = school-based activities = goal setting = goal review = problem solving = decision making = individual tailoring = asking skills

Parent intervention

PE teacher and curriculum = norms for what PE teachers do = self-efficacy to implement curriculum

PE environmental factors

Overall faculty = faculty support of the program and place of health in the school

SFS staff = outcome efficacy = self-efficacy to implement food service changes = norms for school staff

Administration = PE policies = SFS policies

Parents = make items available and accessible at home

SFS environmental factors = reduce NSLP to 700-800 kcal/meal by changing energy density to lower fat and more fiber = improve presentation of healthy foods = increase NSLP participation = change vending to more water = change snack bar to lower kcal (smaller portions, less fat), more FV, more water, less sweetened beverages

Diet and PE child psychosocial factors = preferences = self-efficacy = outcome expectancies = intrinsic motivation = barriers to PE = barriers to school lunch = knowledge of appropriate portion sizes

Home environmental factors = child's perception of availability and accessibility of FV, PA facilities and opportunities

Interventions Teacher/Staff/Parent Mediating VariablesEnvironmental and Psychosocial Mediators

Fruit and vegetable consumption = increase to 5-9 servings/dayDietary fat intake = decrease to 30% kcalBeverage consumption = increase water to 5-8 cups/day = decrease sweetened beverages to no more that one 12-ounce serving/day

Moderate to vigorous physical activity = increase to 3 bouts/week of 25-30 minutes each in school = increase to 3 bouts/week of 25-30 minutes each outside school

Inactivity = decrease TV watching and e-gaimes to 2 hours/day or less

Targeted Behaviors

Figure 1.3.3 Conceptual Model of STOPP-T2D Prevention Intervention


Process Evaluation as Mediators

Design &

Development of

Intervention

Content-Types-Levels

N1 Exposure Initial Use Continued Use-Preference -Type -Type-Extent -Amount -Amount

Implementation-Fidelity-Extent

N2 Exposure Initial Use Continued Use-Preference -Type -Type-Extent -Amount -Amount

Resources -Types-Levels

Nk Exposure Initial Use Continued Use-Preference -Type -Type-Extent -Amount -Amount

Reach-Depth-Spread

BARRIERS

-Type-Diff

(Baranowski T, Stables G. Process Evaluation of the 5-A-Day Projects. Health Education &Behavior 2000, 27:157-166.)


Intervention Implementation

• What are the 5 major contributors to obesity in each age group?– Provide foci for intervention

• How much change is needed to move physiological variables?– Need more controlled research, diet & PA– How much change get when move physical

variables?



• Need for innovation

– Basic research on manipulating moderators

– New procedures• Cameras with statements• Low cost / non curricular• Interactive multimedia games



• Need innovation (continued)– New theories

• Self concept/cognitive dissonance• Theory of planned behavior (EU)• Family influences• Food shopping?

– New locations• Summer day camp

• Gender & age difference in design - especially PA


Implementation Psychosocial Change

• Need to monitor implementation (50%, 22%)

• Need to find ways around classroom teachers

• New PS measures - IRT?


Psychosocial Change Behavior Change

• Need more basic correlates research– Not enough range in normal PS or behavior to

detect relationships?– Random (chaos theory) or determinate?

• Need mediating variables analyses• Need moderating variable analyses

– Gender– SES– Local environment


Behavior Change Psychosocial Change Adiposity Change

• Does BMI discourage PA? When?

• PROP sensitivity predispose to obesity?

• Role of the hormones (leptin, ghrelin) in obesity prevention?

– Mediating vs. moderating effects?


Need a National Discussion

• Role of schools?

• Role of families?

• Role of government?

• Role of child agencies?

– Boy Scouts, YMCA


Thank You for Listening!

Merci Beaucoup!

Muchas Gratias!

Epharisto!

Tack Så Mycket!

Dzienkuje Bardzo!

usda/nopc 2004 individual changes from intervention: how much can we expect? tom baranowski, ph.d....

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