1. How Do We Design Effective, Integrated Nutrition Education Programs: Research Needs
Isobel Contento, Ph.D., CDN
Department of Health and Behavior Studies
Teachers College, Columbia University
National Obesity Prevention Conference, October 27, 2004
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.

2. Hunger/satiety mechanisms Sensory specific satiety
Environmental
factors:
Intra-personal
factors:
Social
environment:
Social networks &
relationships
Cultural practices
Experience with food:
Associative conditioning
Beliefs
Attitudes
Expectancies
Benefits
Barriers
Self-efficacy
Self identity
Moral/ethical
Stage in
change process
Knowledge &
skills
Biologically
determined
behavioral
predispositions:
Taste/pleasure
Sweet, sour, salt, bitter
Hunger/satiety mechanisms
Sensory specific satiety
Brain mechanisms
Physiological
conditioning:
Familiarity:
learned safety
Conditioned
preferences
Conditioned satiety
Physical
environment
Food availability
(under & over)
Technology
Economic
environment
Resources
Price
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
Social conditioning:
Models
Rewards
Social affective
context
Interpersonal
factors:
Social norms
Cultural norms
Informational
Environment
•Advertising
•Education
Media
FOOD
BEHAVIORS
Contento 2000

3. Hunger/satiety mechanisms Sensory specific satiety
Environmental
factors:
Intra-personal
factors:
Social
environment:
Social networks &
relationships
Cultural practices
Experience with food:
Associative conditioning
Beliefs
Attitudes
Expectancies
Benefits
Barriers
Self-efficacy
Self identity
Ethical/moral obligations
Ethnic
identities
Stage in
change process
Knowledge &
skills
Biologically
determined
behavioral
predispositions:
Taste/pleasure
Sweet, sour, salt, bitter
Hunger/satiety mechanisms
Sensory specific satiety
Brain mechanisms
Physiological
conditioning:
Familiarity:
learned safety
Conditioned
preferences
Conditioned satiety
Physical
environment
Food availability
(under & over)
Technology
Economic
environment
Resources
Price/cost
Thus interventions for overweight prevention need to address all these factors.
Social conditioning:
Models
Rewards
Social affective
context
Interpersonal
factors:
Social norms
Cultural norms
Informational
Environment
•Advertising
•Education
Media
Contento, SNE, July 27, 2003
NUTRITION
INTERVENTIONS

4. 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
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:
Gregson, Forester, Orr, et al., JNE, 2001;33:S4-15
McLeroy, Bibeau, Steckler, Glanz. Health Ed Q. 1988;15:

5. Policy Individual Systems Local, state, federal Spheres of Influence
Social structure
Institutional/
organizational
Interpersonal
factors:
Rules, policies,
informal networks
Policy
Individual
Biological givens
Experience with food
Beliefs, attitudes
Knowledge
Family
Peers
Social networks
Systems
Community
Social networks
Norms
Standards
Local, state,
federal
This has led to the social ecological model; where interventions are directed at all levels or spheres of influence
Spheres of Influence
Interventions

6. OVERWEIGHT PREVENTION STUDIES

7. 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
Community adults
Ages 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
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)

8. 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
min lessons for goal-setting
BMI + TSF
p<.05 for girls
TV *
Fat & cals *girls
F&V *girls
PA - ns
Robinson
3-4th graders
(n=192)
TV/video
18 lessons- 2 mo.
TV turnoff for 10 days
TV --> 7 hr/week
Home - newsletters
+TV time manager
BMI*, TSF *
Meals w/TV *
PA -ns
Hi fat foods -ns
Gortmaker; 4 subject areas= language arts, math, science and social studies

9. 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
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

10. 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

11. 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*
Minnesota
8-10 yr old
AA girls + families
(n=54)
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

12. 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
Tennessee
8-10 yr old
AA girls +
families
(n=60)
Sweetened beverages
Water
Child weekly sessions
Parent sessions
12 weeks
BMI, waist -tr
Sweet bev. - 34%
Water %
MVPA - 12%
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.

13. DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation issues

14. 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
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 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.

15. 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?
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 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

16. 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
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 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

17. 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
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 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

18. 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}

19. DESIGNING PROGRAMS: RESEARCH NEEDS
Theory:
Nutrition/ ---> change in predictors --> change in
PA of behaviors behaviors
interventions specified by theory
(mediating variables)

20. 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;19:17-40
Baranowski et al. Am J Prev Med 1998;15:
Baranowski et al. Obesity Res 2003;11:23S-43

21. 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
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 weeks; the most intense seemed to be sessions 2 years in a row; or TV monitors in the home. )
Fidelity to the intervention as designed was often very low.

22. 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

23. 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.

24. 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

25. DESIGNING PROGRAMS: RESEARCH NEEDS
Behavioral targets
Theory
Intervention /Strategies
Evaluation and Measurement issues

26. Leverage points Interventions
Social structure
Institutional/
organizational
Interpersonal
factors:
School meals
Physical education
Worksites
Policy
Individual
Biological givens
Experience with food
Beliefs, attitudes
Knowledge
Family
Peers
Social networks
Systems
Community
Community
programs
Bike-paths
This has led to the social ecological model; where interventions are directed at all levels or spheres of influence
Food system
Leverage points
Interventions