# Presentation: 862577

**Isobel Contento, Ph.D., CDN**
**Department 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**

**Notes:**
I am pleased to be here this morning.  We have learned a great deal from the conference so far. 
I am reminded of an ad that I saw on TV this summer. 

It was an ad for a bug spray. 
A  young man is sitting in a tent, in shorts and a bare top. There are dozens and dozens of mosquitoes INSIDE the tent with him.  But because he this bug spray on him, he is able to resist all the mosquitoes from biting him.   

I think that what we have learned so far is that we are not going to find a bug spray that will help us prevent overweight, that will enable us to resist all of our biological predispositions to liking for high calorie foods and the environmental forces that capitalize on them. Not does there seem to be a biological drive for us to increase our PA sufficiently in response to excess energy intake.

## FOOD

**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:**

**Social**
**environment:**
**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**

**Economic**
**environment**
**Resources**
**Price**

**Notes:**
Yesterday we learned that many factors influence our food choices and dietary behaviors as shown in this slide.
This is a modification of the graphic produced by the Partnership to Promote Healthy Eating and Active Living
Biologically determined behavioral predispositions. 

Experience with food.

adequate exposure to healthful foods  for familiarity effects and associative conditioning

Etc. 
A similar series of concentric circles can be constructed for influences on PA 

##  Environmental 

**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:**

**Social**
**environment:**
**Social networks &**
**    ****relationships**
**Cultural practices**

**Physical **
**environment**
**Food availability**
**    ****(under & over)**
**Technology**

**Informational **
**Environment**
**•****Advertising**
**•****Education**
**Media**

**                 ****Interpersonal**
**                 ****factors:**
**Social norms**
**Cultural norms**

**NUTRITION**
**INTERVENTIONS**

**Contento, SNE, July 27,  2003**

**Economic**
**environment**
**Resources**
**Price/cost**

**Notes:**
Thus interventions for overweight prevention need to address all these factors.

## 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:S4-15**
**McLeroy, Bibeau, Steckler, Glanz. Health Ed Q. 1988;15:351-377**

**Notes:**
1. Is nutrition education effective?
Main conclusion in 1995 was carefully worded to say that NE works in the sense that NE is a significant factor in improving dietary practices when behavioral change is set as the goal and educational strategies employed are designed with that as a purpose. 
Seems uncontroversial – yet

I am asking the question because it is still being asked government circles in the US. 
USDA – Bost skeptical

National data in US: it could be argued that since obesity is on the rise; and average fat intake is still above 30% of calories and the % eating 5+ F&V is only 26%, nutrition education is not effective. 
BUT
Evidence from studies show a positive intervention effect. Several reviews:

## Individual

**Individual**
**Biological 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 networks**
**Norms **
**Standards**

**Rules, policies,**
**informal networks**

**Notes:**
This has led to the social ecological model; where interventions are directed at all levels or spheres of influence

**OVERWEIGHT PREVENTION STUDIES**

## OVERWEIGHT PREVENTION STUDIES

| Study | Target Group  | Target Behaviors | Intervention | Findings |
| --- | --- | --- | --- | --- |
| Donnelly, 
1996
CCT | 3-5th graders

n =338
 | Metabolic fitness via diet and PA | School meals - lower fat
NE - 9 sessions/year
PA -- 3x week | At end of yr 2:
BMI  - ns
Metabolic fitness - ns |
| Flores,  
1995
RCT | 10-13 yrs
AA, Hispanic
n =110 | Aerobic exercise | Aerobic dance in school PE 3x week, 12 weeks | BMI p<.05 girls |
| Jeffery & French
1997
RCT  | 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 |

**Notes:**
Donnelly
Two schools in rural Nebraska - matched for ethnicity and SES status:  one intervention school and one control 

Flores
Substituted aerobic dance for the usual PE in school

Jeffrey and French have done numerous studies in the obesity area. This one is on overweight prevention --Pound of Prevention 
Education only group (25% of participants) Newsletter monthly with a stamped return postcard. They filled in the frequency of recommended behaviors such as weighing and their current weight.
Education plus lottery had their names entered into a $100 monthly lottery if they returned the postcard.

(Participants could participate in a face-to-face weight control short course conducted by a health educator, aerobics classes, group walks, exercise facilities with free childcare, a correspondence weight control course, a one-month membership of  exercise facilities,  a marathon, a recipe context, and the 5&3 challenge: exercise 20min  and eat 5 F&V 3x  week)

## OVERWEIGHT PREVENTION STUDIES

| Study | Target Group  | Target Behaviors | Intervention | Findings |
| --- | --- | --- | --- | --- |
| Gortmaker 
1999
Cluster RCT

Planet 
Health | 6-8th graders
Mixed ethnicity

(n=1295)
 | TV /video
Hi-fat foods
F&V
MVPA |  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 *girls
F&V *girls
PA - ns |
| Robinson
1999
Cluster 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 |

**Notes:**
Gortmaker; 4 subject areas= language arts, math, science and social studies

## OVERWEIGHT PREVENTION STUDIES

| Study | Target Group  | Target Behaviors | Intervention | Findings |
| --- | --- | --- | --- | --- |
| Pathways:
Caballero
2003
RCT | 3-4th graders
American 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 - ns
BMI - ns
% fat in school lunch*
24-hr recalls: calorie intake*
% fat*
Accelerometer- ns
PA Quest - ns |

**Notes:**
Pathways
Ongoing NHLBI study to demonstrate the efficacy of school-based primary prevention of obesity. RCT 41 schools (21 Int and 20 control) in 7 American Indian communities.  N= 2000

## OVERWEIGHT PREVENTION STUDIES

| Study
(pilot) | Target Group  | Target Behaviors | Intervention | Findings |
| --- | --- | --- | --- | --- |
| Neumark-Sztainer
2003

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 |
| --- | --- | --- | --- | --- |
| GEMS
Stanford, CA
2003 | 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 - tr
Self  TV - tr
Family TV* Dinners w/TV*
Concern weight* |
| GEMS 
Minnesota
2003
 | 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 |
| --- | --- | --- | --- | --- |
| GEMS
Baylor, 
TX
2003 | 8-10 yr old AA girls +
Families
(n=35) | FJV 
PA |  4-week summer 
 8-week home Internet 
 | BMI -tr
Other measures -tr |
| GEMS
Tennessee
2003
 | 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%
 |

**Notes:**
As we can see, there have not been many studies of overweight prevention and most of these to date have not been too effective.  Several studies have been recently initiated and these should provide us with much needed information.

I would like to share with you some reflections and suggestions to think about in future studies. 

## 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**

**Notes:**
It can be seen that a few studies targeted sedentary behaviors only.  Most targeted both eating patterns and PA.  

Many  previous studies directed at heart health also targeted these same behaviors, but did not result in overweight prevention. It may be that it is time for our curricula and interventions to face the calorie issue head on. 
That is, it may be that we cannot just ask participants to increase their F&V intake and hope that it will crowd out the higher calorie, less nutrient dense foods; or to increase water consumption and hope that will  crowd out sweetened beverages.

When the Dietary Goal for the US was first published in 1977 -- the precursor of the Dietary Guidelines-- Mark Hegsted who was instrumental in bringing forth the Dietary Goals, said: “In the past, the message was, in essence, to eat more of everything. Now we are faced with the difficult problem of teaching the public to be more discriminating. Increasingly, the message will be to eat less”.   A man  ahead of  his time.

## 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**
**Weight as outcome?**

**Notes:**
Perhaps it is time to focus on dietary restraint as a behavioral target -- NOT disordered eating; (even in the restrained eating literature dietary restraint is a measure of the extent to which CONSCIOUS control is exerted on food intake.) 

Jim Hill has noted that Americans’ penchant for large portion sizes may be due to the high value we place on getting more for less; we want things big -- and cheap. 

In  an article on “From instinct to intellect: the challenge of maintaining healthy weight in the modern world,” he and colleagues have noted that the current environment presents a constant background that promotes weight gain.

• Human physiology developed to function within an environment where food was scarce and PA was high.  The opposite now pertains. 
• Thus the modern environment has taken body weight control from an instinctual (unconscious) process to one that requires substantial cognitive effort.  People who are not devoting substantial conscious effort to managing body weight are probably gaining weight. 

There is evidence that dietary restraint can result in a more  healthful food choices;  and weight control in the face of high fat foods. 
The 2005 Dietary Guidelines finally, 40 years after Hegsted’s comment, says something about calorie:
“Control calorie intake to mange body weight” They note that a calorie deficit of 50-100 calories a day may enable many adults to maintain their eight rather than continuing to gain weight each year. For children who are gaining excess fat, a similar small decrease can reduce the rate of weight gain so that as they age they will grow into a healthy weight. 
One graphic of the FGP  says to eat PLENTY of the bottom, eat MORE of the next layer, ENOUGH of the next and EAT SPARINGLY  of the tip of the pyramid.
W e seem to have forgotten the EAT SPARINGLY  of the tip of the pyramid.  

WE NEED TO EXPLORE how this DIETARY RESTRAINT notion SHOULD BE STATED.

It is unfortunate that the phrase “dietary restraint” now means to many professionals is associated with disordered eating. I am not sure what  restricted eating

## 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**
**  ****	****	****	**

**Notes:**
Perhaps it is time to focus on dietary restraint as a behavioral target -- NOT disordered eating; (even in the restrained eating literature dietary restraint is a measure of the extent to which CONSCIOUS control is exerted on food intake.) 

Jim Hill has noted that Americans’ penchant for large portion sizes may be due to the high value we place on getting more for less; we want things big -- and cheap. 

In  an article on “From instinct to intellect: the challenge of maintaining healthy weight in the modern world,” he and colleagues have noted that the current environment presents a constant background that promotes weight gain.

• Human physiology developed to function within an environment where food was scarce and PA was high.  The opposite now pertains. 
• Thus the modern environment has taken body weight control from an instinctual (unconscious) process to one that requires substantial cognitive effort.  People who are not devoting substantial conscious effort to managing body weight are probably gaining weight. 

There is evidence that dietary restraint can result in a more  healthful food choices;  and weight control in the face of high fat foods. 
The 2005 Dietary Guidelines finally, 40 years after Hegsted’s comment, says something about calorie:
“Control calorie intake to mange body weight” They note that a calorie deficit of 50-100 calories a day may enable many adults to maintain their eight rather than continuing to gain weight each year. For children who are gaining excess fat, a similar small decrease can reduce the rate of weight gain so that as they age they will grow into a healthy weight. 
One graphic of the FGP  says to eat PLENTY of the bottom, eat MORE of the next layer, ENOUGH of the next and EAT SPARINGLY  of the tip of the pyramid.
W e seem to have forgotten the EAT SPARINGLY  of the tip of the pyramid.  

WE NEED TO EXPLORE how this DIETARY RESTRAINT notion SHOULD BE STATED.

It is unfortunate that the phrase “dietary restraint” now means to many professionals is associated with disordered eating. I am not sure what  restricted eating

## 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**
**  ****	****	****	**

**Notes:**
Perhaps it is time to focus on dietary restraint as a behavioral target -- NOT disordered eating; (even in the restrained eating literature dietary restraint is a measure of the extent to which CONSCIOUS control is exerted on food intake.) 

Jim Hill has noted that Americans’ penchant for large portion sizes may be due to the high value we place on getting more for less; we want things big -- and cheap. 

In  an article on “From instinct to intellect: the challenge of maintaining healthy weight in the modern world,” he and colleagues have noted that the current environment presents a constant background that promotes weight gain.

• Human physiology developed to function within an environment where food was scarce and PA was high.  The opposite now pertains. 
• Thus the modern environment has taken body weight control from an instinctual (unconscious) process to one that requires substantial cognitive effort.  People who are not devoting substantial conscious effort to managing body weight are probably gaining weight. 

There is evidence that dietary restraint can result in a more  healthful food choices;  and weight control in the face of high fat foods. 
The 2005 Dietary Guidelines finally, 40 years after Hegsted’s comment, says something about calorie:
“Control calorie intake to mange body weight” They note that a calorie deficit of 50-100 calories a day may enable many adults to maintain their eight rather than continuing to gain weight each year. For children who are gaining excess fat, a similar small decrease can reduce the rate of weight gain so that as they age they will grow into a healthy weight. 
One graphic of the FGP  says to eat PLENTY of the bottom, eat MORE of the next layer, ENOUGH of the next and EAT SPARINGLY  of the tip of the pyramid.
W e seem to have forgotten the EAT SPARINGLY  of the tip of the pyramid.  

WE NEED TO EXPLORE how this DIETARY RESTRAINT notion SHOULD BE STATED.

It is unfortunate that the phrase “dietary restraint” now means to many professionals is associated with disordered eating. I am not sure what  restricted 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 behaviors**
**Behavioral ****	****}                      ****(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 (r****2**** < 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;19:17-40**
**	****	****	****	****Baranowski et al. Am J Prev Med 1998;15:266-297**
**	****	****	****	****Baranowski 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**

**Notes:**
Duration was most often short and intensity low -- compared to 3 hrs a week of food ads on TC, food everywhere and sedentary behavior the norm. 

(Most of the studies were 1-3 hours a week for something like 12 -18 weeks; the most intense seemed to be 12-18 sessions 2 years in a row; or TV monitors in the home. )

Fidelity to the intervention as designed was often very low.  

## 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**

## Individual

**Individual**
**Biological givens**
**Experience with food**
** ****Beliefs, attitudes**
**Knowledge**

**  ****Interpersonal**
**            ****factors**:

**Family **
**Peers**
**Social networks**

**Institutional/**
**organizational**

** ****Social structure**

**Interventions**

**Community**

**Policy**

**Systems**

**Community **
**programs**
**Bike-paths**

**School meals **
**Physical education**
**Worksites **

| Leverage points |
| --- |

**Food system**

**Notes:**
This has led to the social ecological model; where interventions are directed at all levels or spheres of influence