Isobel Contento, Ph.D., CDN Department of Health and Behavior Studies Teachers College, Columbia University

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

2. 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 • Social conditioning: • Models • Rewards • Social affective • context • Interpersonal • factors: • Social norms • Cultural norms • Informational • Environment • •Advertising • •Education • Media FOOD BEHAVIORS Contento 2000

3. 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 • 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 Gregson, Forester, Orr, et al., JNE, 2001;33:S4-15 McLeroy, Bibeau, Steckler, Glanz. Health Ed Q. 1988;15:351-377

5. 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 Interventions

6. OVERWEIGHT PREVENTION STUDIES

7. OVERWEIGHT PREVENTION STUDIES

8. OVERWEIGHT PREVENTION STUDIES

9. OVERWEIGHT PREVENTION STUDIES

10. OVERWEIGHT PREVENTION STUDIES

11. OVERWEIGHT PREVENTION STUDIES Girls health Enrichment Multi-site Studies

12. OVERWEIGHT PREVENTION 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

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?

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

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

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;15:266-297 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

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-sectionaland/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. 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 Food system Interventions