Nutrition Education: Linking Research, Theory, and Practice

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Nutrition Education Linking Research, Theory,
and Practice

• Isobel Contento, Ph.D.
• Program in Nutrition
• Department of Health and Behavior Studies
• Teachers College Columbia University
• New York City, USA
• Sacramento January 23, 2008

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Environmental factors

• Physical/food
• environment
• Food availability
• (under over)
• Technology

Intra-person factors
Experience with food Associative
conditioning

• Perceptions
• Attitudes
• Beliefs

• Social
• environment
• Social influences
• Cultural practices
• Social structures, organizations
• Policy

• Biologically
• determined
• behavioral
• predispositions
• Taste/pleasure
• Sweet, sour, salt, bitter
• Hunger/satiety mechanisms
• Sensory specific satiety
• Brain mechanisms

• Physiological
• conditioning
• Familiarity
• learned safety
• Conditioned food
• preferences
• Conditioned satiety

• Motivations values
• Personal meanings
• Knowledge skills

• Economic
• environment
• Resources
• Price
• Time

• Social norms
• Cultural norms

Social conditioning

• Models
• Rewards
• Social affective
• context

Inter-person factors
Informational Environment
Family social networks

• Advertising
• Education
• Media

FOOD CHOICE AND DIET-RELATED BEHAVIORS
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Factors Influencing Food Choice Dietary
Behaviors and the Role of Nutrition Education
Environmental factors
Physical/food environment
Person-related factors

• Food availability
• (under over)
• Technology

Experience with food Associative
conditioning

• Perceptions
• Attitudes
• Beliefs

• Biologically
• determined
• behavioral
• predispositions
• Taste/pleasure
• Sweet, sour, salt, bitter
• Hunger/satiety mechanisms
• Sensory specific satiety
• Brain mechanisms

• Social
• environment
• Social networks
• Cultural practices
• Social structures, organizations
• Policy

• Physiological
• conditioning
• Familiarity
• learned safety
• Conditioned food
• preferences
• Conditioned satiety

• Motivations values
• Personal meanings
• Knowledge skills

• Economic
• environment
• Resources
• Price
• Time

• Social norms
• Cultural norms

Social conditioning

• Models
• Rewards
• Social affective
• context

Informational Environment

• Advertising
• Media

NUTRITION EDUCATION
Contento 2000
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Social-Ecological Model Levels of Influence for
nutrition education interventions
Institutional/ Organizational level
Interpersonal level
Policy and systems
Workplaces, schools, organizations Rules,
policies, informal structures
Individual level Food preferences
enjoyment Beliefs, attitudes,
values, Knowledge, Social and cultural
norms Self-efficacy Empowerment
Family, peers, friends, health professionals
Social structure
Public policy
Social roles
Social networks
Community level
Systems
Collective empowerment
-- Local, state, federal
Neighborhoods
Social networks Norms
Nutrition Education
Media
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Is nutrition education effective?
Based on a review of studies Nutrition education
is a significant factor in improving dietary
practices when behavioral change is set as the
goal and educational strategies are designed with
that as a purpose
Review of effectiveness. Contento et al, JNE
1995, FCC 2002
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Key elements of effectiveness in nutrition
education

• Focuses on specific behaviors, actions,
  practices, or issues
• Identifies and addresses influences on behaviors
• Influences determinants of behavior or
• potential mediators of behavior change

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Key elements of effectiveness in nutrition
education

• Develops theory to help us understand
  relationships between potential mediators and
  behavior/ actions
• Uses theory and research to design educational
  strategies directed at these potential mediators
• Addresses the multiple levels of influences

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Definition of nutrition education

• Nutrition education is any combination of
  educational strategies, accompanied by
  environmental supports, designed to facilitate
  voluntary adoption of food choices and other food
  and nutrition-related behaviors conducive to
  health and well-being (of individuals, community,
  planet)
• Nutrition education is delivered through multiple
  venues and involves activities at the individual,
  community, and policy levels.

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Is nutrition education effective? Studies with
adults
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Is nutrition education effective? (Adults)
FV Intake Fat Intake (22
studies) (79 studies) Meta-analysis
na Differences in deltas
Significant or not
17/22 68/79 Average intake 0.6
servings 7.3fat calories (NCI 92 studies from
907 reviewed that met criteria) Efficacy of
interventions to modify dietary behavior related
to cancer risk (Report/Technology Assessment
Number 25. Agency for Healthcare Research and
Quality. USDHHS, Public Health Service. 2001
Ammerman Prev Med 2002)

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Is nutrition education effective? (FV)
Pomerleau Lock, Knai McKee, J Nutr 2005
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• Studies with children

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School-based FV interventions
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School-based FV interventions
Howerton JNEB 200739186-196
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Overweight Prevention Reviews
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What can we conclude?

• Nutrition education is effective -- but not
  across the board
• We have not identified all/ appropriate
  mediators
• We do not have clearly demonstrated effective
  strategies for each mediator
• Is glass half full or half empty?

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Mediators in nutrition education
Nutrition Education Intervention
? Mediators (influences)
? Behavioral Outcomes
Baranowski, Lin, Wetter et al. Ann Epidemiol
1997 S89-95
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Theory in nutrition education

• A conceptual map, derived from evidence, to help
  us understand how various influences on
  food-related behavior are related to behavior/
  taking action

BiologicalPsychologicalBehavioralEnvironmental
Mediators (influences)
Diet PA behaviors
predict
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Nutrition education is about identifying and
addressing relevant mediators of change
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Simple mediating/ moderating variable model
Social/behavior moderating variables
Intervention
Mediating variables
Outcomes
Baranowski, SNE 2007
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Pre-1995 knowledge based programs
SES, social variables
Intervention
Knowledge
Behavior
Baranowski, SNE 2007
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1995-2005 theory- based programs
Social/ behavioral moderators
Intervention
Psycho- social variables
Behavioral outcomes
Baranowski, SNE 2007
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2005-now Theory social-ecological programs
Moderating variables
Intervention
Environment
Psycho- social variables
Behavioral outcomes
Baranowski, SNE 2007
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Double mediation model
Social / behavioral moderators
Intervention
Mediating variables
Physiological moderators
Behavioral outcomes
Health outcomes
Health outcomes from behavior change programs
Baranowski, SNE 2007
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Multiple mediation model
Parent education
Moderating variables
Parent mediating variables
Home environment
Parent behaviors
Child psychosocials
Child behaviors
Child health outcomes
Family based programs
Baranowski, SNE 2007
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Multiple mediation model Impacts
Parent education
Moderating variables
Parent mediating variables
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Home environment
Parent behaviors
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6.25
12.5
Child psychosocials
Child behaviors
Child health outcomes
Family based programs
3.13
Baranowski, SNE 2007
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Potential mediators

• Belief in diet-disease connection
• Beliefs about outcomes ( and -)
• Perceived susceptibility/threat
• Attitudes
• Self-efficacy
• Pros cons of change (benefits barriers)
• Others
• In most studies, variance accounted for by
  variables studied about 30

Baranowski, 1999
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Potential mediators

• Self-identity green consumerism - Sparks, Soc
  Psych Q, 1992
• Ethical obligation and biotech food - Sparks,
  Basic Appl Soc
• Psych, 1995
• Moral obligation for family - Raats,
  1995
• Ethnic identity - Devine, JADA 1999
• Ecological concerns perceived
• responsibility to take action - Bissonette
  Contento
• JNE 2001

Correlational studies
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Determinants/ potential mediators of FV for
children

• Age
• Gender
• SES
• Preferences
• Parental intake
• Home availability/ accessibility
• Rasmussen, Krolner Klepp, 2006

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Nutrition education phases or components based on
theory evidence
Motivational pre-action phase / component Focus
on why-to take action
Action and maintenance phase / component Focus
on how-to take action
Environmental support component
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Using Theory in Nutrition Education
Motivational pre-action phase Why-to take
action
Action and maintenance phase How-to take action
Action Pros gt Cons Self-efficacy
Contemplation Cons gt Pros of Change
Maintenance
Precontemplation
Preparation
Transtheoretical Model Stages of Change
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A Logic Model for Planning Nutrition Education
Inputs What we invest
Outputs What we do
Outcomes With what results
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Conceptual Framework for Theory-Based Nutrition
Education A Logic Model
Inputs/ Resources
Outcomes
Outputs Theory-Based Intervention
Strategies directed at mediators of food choice
and diet-related action
Intervention Activities Conduct
classes Facilitate groups Develop products,
resources Work with families Work with
community partners Work with media Work with
policy makers
Food system impacts
People Time Materials Money Space
Partners Needs assess-ment process

• Motivational phase mediators
• Risks, concerns
• - Benefits, barriers
• - Attitudes
• - Food preferences
• Self-efficacy
• Social norms

• Action phase mediators
• Action plans
• Knowledge
• Food skills
• Self-regulation skills
• Personal
• agency

Food behaviors/ practices Fruits
vegetables Calcium rich foods Resource
management. etc
Improved health Decreased disease
risk Decreased food insecurity
Societal impacts

• Environmental Supports
• Interpersonal social support
• - Institutional/ community actions
• - Policies, systems, food environment

Contento, 2002, c2007
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Nutrition Education Logic Model Addressing
Multiple Levels of Intervention
Inputs/ Resources
Outcomes
Outputs
Activities / Venues
Short
Medium
Long term
Individual Interpersonal level (Individuals,
households, groups)
Individuals in groups
People Time Materials Money Space
Partners Needs assess- ment process
Educational programs in person indirect
social marketing
Learning motivation
Use skills, take action
Decreased disease risk
Use skills, take action
Organizational community level (Partnerships
collaborations)
Partners Communities
Strategies to develop social support and
partnerships to reduce barriers, increase
collective efficacy, empowerment
Increase awareness, collective efficacy
Commit to change
Solve community problems
Policy, systems food environmental level
(collaborations)
Policy makers
Create/ revise policy, social systems, food
environments
Identify define issues
Work towards change
Adopt/ revise policy
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Step 1 Select behavior or action
Select behavior or community action that will be
the focus of the program based on needs
analysis
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• Choice, Control, and Change (C3)
• Using theory to design an inquiry-based science
  curriculum for middle school students for obesity
  prevention

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Needs Analysis

• Identify behaviors in middle school children
  contributing to risk of overweight
• Fruits vegetables low
• Sweet beverages high
• Packaged sweet salty snacks high
• Fast food places high
• Inactive

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Needs Analysis

• Objective data
• Health data
• Policy documents
• State dietary status for low-income children
  families
• Subjective data
• Focus groups
• Behavioral focus Increase fruit vegetable
  intakes

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Step 2Identify potential mediators

• Identify personal psychosocial mediators
• Awareness of health consequences e.g. diabetes
  metabolic syndrome
• Anticipated personal benefits convenience,
  taste, feeling full, cost
• Reduce barriers to healthy eating
• Increase confidence/ competence in healthful
  personal choices (empowerment)

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Identify potential environmental mediators
Reduce barriers to healthy eating -- school
meals -- school food environment Reduce
barriers to being physically active -- activity
during recess -- provide pedometers
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Identify potential mediators

• Focus groups Perceptions of motivations,
  benefits, barriers, and information channels
• Benefits for health already known
• Barriers difficult to add to diet
  inconvenient
• cost (families)
• taste familiarity (children)

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Identify potential mediators

• Positive attitude toward eating fruits and
  vegetables already existed
• Wanted clear idea of what to do and how to do
  it. Preferred colorful and bold messages.

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Step 3 Select theory or create model
Select theory based on research evidence for
behavior and population
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An integrative model for health behavior change
Background Influences
Past Behavior
Environment Physical, social, economic, policy,
systems
Beliefs about behavior value of outcomes
Demographics and culture
Attitudes
Food preferences prior experience with food
Beliefs of others motivation to comply
Social Norms (peer pressure
Behavior
Action plans
Intention
Personality, moods, emotions
Beliefs about control over behavior power
Self-efficacy
Skills abilities
Other individual differences (perceived risk)
Motivation phase
Action phase
Media exposure
(Kok et al, 1996 Abraham et al., 1998 Institute
of Medicine, 2002)
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C3 Theoretical framework an integrative model
Why to take action
How to take action
Self Regulation processes Goal setting Knowledge
and skills
Assessment of personal practices/risk
Long-term Goal Becoming competent eater and
movers Healthy lifestyle Overweight prevention
Behavioral goals Food ? Sweetened beverages ?
Fast food restaurants ? Packaged snacks ? Water ?
FV Physical activity ?Walking
Self-efficacy for specific tasks
Beliefs about outcomes Scientific evidence
Perceived Competence (eating and physical
activity)
Beliefs about barriers
Behavioral Intention
Attitudes
Subjective norm
Beliefs about behavioral control
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C3 Theoretical framework an integrative model
Why to take action
How to take action
Self Regulation processes Goal setting Knowledge
and skills
Assessment of personal practices/risk
Long-term Goal Becoming competent eater and
movers Healthy lifestyle Overweight prevention
Behavioral goals Food ? Sweetened beverages ?
Fast food restaurants ? Packaged snacks ? Water ?
FV Physical activity ?Walking
Self-efficacy
Beliefs about outcomes scientific evidence
Perceived Competence (eating and physical
activity)
Beliefs about barriers
Behavioral Intention
Attitudes
Subjective norm
Beliefs about behavioral control
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C3 Theoretical framework an integrative model
Why to take action
How to take action
Assessment of personal practices/risk
Self Regulation Processes Goal setting Knowledge
and skills
Self-efficacy
Long-term Goal Becoming competent eater and
movers Healthy lifestyle Overweight prevention
Behavioral goals Food ? Sweetened beverages ?
Fast food restaurants ? Packaged snacks ? Water ?
FV Physical activity ?Walking
Beliefs about outcomes Scientific evidence
Perceived Competence (empowerment)
Beliefs about barriers
Behavioral Intention
Attitudes
Subjective norm
Beliefs about behavioral control
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Program components

• 24 science nutrition education lessons (5
  units)
• Taught by school science teachers
• Professional development sessions
• Biology, environment personal behavior

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Program components

• Field trips to labs
• Inquiry-based experiments
• Parent newsletters

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Theory components

• Theory
• Health Belief model, focusing on overcoming
  barriers
• Components
• Mass media campaign
• Classroom lessons
• Grocery stores
• Community outreach

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Conceptual Framework for Theory-Based Nutrition
Education A Logic Model
Inputs/ Resources
Outcomes
Outputs Theory-Based Intervention
Strategies directed at mediators of food choice
and diet-related action
Intervention Activities Conduct
classes Facilitate groups Develop products,
resources Work with families Work with
community partners Work with media Work with
policy makers
Food system impacts
People Time Materials Money Space
Partners Needs assess-ment process

• Motivational phase mediators
• Risks, concerns
• - Benefits, barriers
• - Attitudes
• - Food preferences
• Self-efficacy
• Social norms

• Action phase mediators
• Action plans
• Knowledge
• Food skills
• Self-regulation skills
• Personal
• agency

Food behaviors/ practices Fruits
vegetables Calcium rich foods Resource
management. etc
Improved health Decreased disease
risk Decreased food insecurity
Societal impacts

• Environmental Supports
• Interpersonal social support
• - Institutional/ community actions
• - Policies, systems, food environment

Contento, 2002, c2007
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Strategies to enhance motivation
Increase awareness of risks or concerns Trigger
films, pictures, charts, striking national or
local statistics, personal stories, pictures of
portion sizes
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Triple by-pass burger
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Strategies to enhance motivation

• Increase perceived benefits
• Personally relevant
• - Health, taste, convenience, weight, self-image
• What they will gain from taking action, and
  what they will lose by not taking action
• Make messages straightforward and clear
  novel, memorable, culturally appropriate

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Taste
Courtesy of FoodChangeR
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Motivating physical activity
Social marketing campaign for 9-11 year olds CDC
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Benefits
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Benefits
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Strategies to enhance motivation

• Decrease perception of barriers to taking action
• Identify barriers to action
• - Health? Taste? Inconvenient?
• Brainstorm ways to overcome barriers personal
  and community wide
• Correct misconceptions that are a barrier

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Pick a better snackTM
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Pick a better snackTM
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Conceptual Framework for Theory-Based Nutrition
Education A Logic Model
Inputs/ Resources
Outcomes
Outputs Theory-Based Intervention
Strategies directed at mediators of food choice
and diet-related action
Intervention Activities Conduct
classes Facilitate groups Develop products,
resources Work with families Work with
community partners Work with media Work with
policy makers
Food system impacts
People Time Materials Money Space
Partners Needs assess-ment process

• Motivational phase mediators
• Risks, concerns
• - Benefits, barriers
• - Attitudes
• - Food preferences
• Self-efficacy
• Social norms

• Action phase mediators
• Action plans
• Knowledge
• Food skills
• Self-regulation skills
• Personal
• agency

Food behaviors/ practices Fruits
vegetables Calcium rich foods Resource
management. etc
Improved health Decreased disease
risk Decreased food insecurity
Societal impacts

• Environmental Supports
• Interpersonal social support
• - Institutional/ community actions
• - Policies, systems, food environment

Contento, 2002, c2007
71
Strategies to facilitate action

• Action plans
• Setting goals for behavior or collective action

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Learning to set action plans
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• Food and nutrition knowledge and skills

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Food and nutrition knowledge and skills
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Food preparation skills
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Conceptual Framework for Theory-Based Nutrition
Education A Logic Model
Inputs/ Resources
Outcomes
Outputs Theory-Based Intervention
Strategies directed at mediators of food choice
and diet-related action
Intervention Activities Conduct
classes Facilitate groups Develop products,
resources Work with families Work with
community partners Work with media Work with
policy makers
Food system impacts
People Time Materials Money Space
Partners Needs assess-ment process

• Motivational phase mediators
• Risks, concerns
• - Benefits, barriers
• - Attitudes
• - Food preferences
• Self-efficacy
• Social norms

• Action phase mediators
• Action plans
• Knowledge
• Food skills
• Self-regulation skills
• Personal
• agency

Food behaviors/ practices Fruits
vegetables Calcium rich foods Resource
management. etc
Improved health Decreased disease
risk Decreased food insecurity
Societal impacts

• Environmental Supports
• Interpersonal social support
• - Institutional/ community actions
• - Policies, systems, food environment

Contento, 2002, c2007
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Social support and healthy cooking skills for
parents
Courtesy of FoodChangeR
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Family night Parents children cooking eating
together
Courtesy of Cooking with KidsTM
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Information environment
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School lunches from this.
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School lunches to this.
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Environmental supports for action
Environmental intervention grocery stores
Shelf labeling Coupons for FV Recipes
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Grocery stores
Pick a better snackTM
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Conceptual Framework for Evaluating Theory-Based
Nutrition Education
Inputs/ Resources
OutcomesShort-term Medium-term Long-term
Outputs Theory-Based Intervention
Strategies directed at mediators of food choice
and diet-related action
Intervention Activities Conduct
classes Facilitate groups Develop products,
resources Work with families Work with
community partners Work with media Work with
policy makers
Motivational mediators Risks, concerns
Benefits, barriers Attitudes Food
preferences Self-efficacy Action mediators Kno
wledge Food skills Goal setting
skills Environmental supports Social
structures Environments Policies
Food system impacts
Motivational phase mediators Risks, concerns
Benefits, barriers Attitudes Food
preferences Self-efficacy Social norms
Action phase mediators Action plans
Knowledge Food skills Self-regulation
skills Personal agency
People Time Materials Money Space
Partners Needs assess-ment process
Food behaviors/ practices Fruits
vegetables Calcium rich foods Resource
management. etc
Bio-chemical risk status Bone markers, Serum
chole-sterol
Improved health Decreased disease
risk Decreased food insecurity
Environmental Supports Interpersonal social
support, collective efficacy Institutional/
community actions Policies, systems
Societal impacts
Nu
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Evaluation Model Addressing Multiple Levels of
Intervention
Inputs/ Resources
Outcome evaluation
Outputs
Activities / Venues
Short
Medium
Long term
Individual Interpersonal level (Individuals,
households, groups)
Individuals in groups
People Time Materials Money Space
Partners Needs assess- ment process
Educational programs in person indirect
social marketing
Learning motivation
Use skills, take action
Decreased disease risk
Use skills, take action
Organizational community level (Partnerships
collaborations)
Partners Communities
Strategies to develop social support and
partnerships to reduce barriers, increase
collective efficacy, empowerment
Increase awareness, collective efficacy
Commit to change
Solve community problems
Policy, systems food environmental level
(collaborations)
Policy makers
Create/ revise policy, social systems, food
activity environments
Identify define issues
Work towards change
Adopt/ revise policy
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Range of outcomes
Progress in preventing childhood obesity
Institute of Medicine, 2007
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Range of outcomes
Progress in preventing childhood obesity
Institute of Medicine, 2007
97
Range of outcomes
Progress in preventing childhood obesity
Institute of Medicine, 2007
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Range of outcomes
Progress in preventing childhood obesity
Institute of Medicine, 2007
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Range of outcomes
Progress in preventing childhood obesity
Institute of Medicine, 2007
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Enhancing program evaluation

• All kinds of evaluation can contribute to our
  evidence base scope depends on program
• Use evidence / theory relevant to specific
  context, culturally relevant
• Build on potential synergies by partnering to
  evaluate
• Advocate for support for surveillance,
  monitoring, and evaluation

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Enhancing effectiveness of nutrition education
Motivational pre-action component Focus on
why-to take action
Action and maintenance component Focus on
how-to take action
Environmental support component
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Enhancing effectiveness of nutrition education

• Requires responsibility -- and action-- by all
  segments of society
• Nutrition education directed at all levels of
  influence
• Synergism from actions by the many
• Coalitions, partnerships, and collaborations
• Involvement of participants at all stages of
  program design, implementation, and evaluation
• Empowerment of participants and educators

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Building evidence

• Greater fidelity to theory in nutrition
  education -- so we can interpret outcomes
• Improve measures of outcomes
• Improve measures of mediators/ influences
• - personal, environmental
• - structural, institutional, systems
• Conduct analyses linking mediators outcomes
  so we can attribute causation to intervention

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Our goal People having access enjoying healthy
food
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Enjoying being active
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A healthier next generation
Courtesy of FoodChangeR