Jerianne Heimendinger

Stages of Change in Adopting Healthy Diets: Fat, Fiber, and Correlates of Nutrient Intake

The stages of change construct, which addresses the readiness to change, has only recently been applied to dietary behavior, such as fat consumption. This article describes the application of the stages of change construct to dietary fat and fiber consumption and examines the association of dietary stages to eating practices and related demographic and psychosocial factors in a large, geographically diverse population of workers. We present results from the baseline survey of 17,121 employees in the Working Well Trial. We assessed stage from an algorithm based on seven items and measured dietary intake with an 88-item food frequency questionnaire. Findings indicated that a greater proportion of the population has actively tried to reduce fat intake than to consume more fiber. Stage of change was associated with fat, fiber, and fruit and vegetable intake in a stepwise manner, as predicted. In multivariate analyses that controlled for demographic characteristics, stage of change predicted between 8 and 13% of the variance in dietary intake, and more than demographic variables. These findings have implications for the design of nutrition interventions and for the evaluation of intermediate outcomes.

Work site-based cancer prevention: primary results from the Working Well Trial.

OBJECTIVES This paper presents the behavioral results of the Working Well Trial, the largest US work site cancer prevention and control trial to date. METHODS The Working Well Trial used a randomized, matched-pair evaluation design, with the work site as the unit of assignment and analysis. The study was conducted in 111 work sites (n = 28,000 workers). The effects of the intervention were evaluated by comparing changes in intervention and control work sites, as measured in cross-sectional surveys at baseline and follow-up. The 2-year intervention targeted both individuals and the work-site environment. RESULTS There occurred a net reduction in the percentage of energy obtained from fat consumption of 0.37 percentage points (P = .033), a net increase in fiber densities of 0.13 g/1000 kcal (P = .056), and an average increase in fruit and vegetable intake of 0.18 servings per day (P = .0001). Changes in tobacco use were in the desired direction but were not significant. CONCLUSIONS Significant but small differences were observed for nutrition. Positive trends, but no significant results, were observed in trial-wide smoking outcomes. The observed net differences were small owing to the substantial secular changes in target behaviors.

Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys

OBJECTIVE The purpose of this study is to assess population-based changes in vegetable and fruit consumption and psychosocial correlates. DESIGN Two nationally representative random digit dial surveys conducted in 1991 and 1997; respondents were queried regarding consumption of and attitudes and knowledge about vegetables and fruit. SUBJECTS/SETTING Respondents were 2,755 and 2,544 adults (in 1991 and 1997, respectively) older than 18 years. STATISTICAL ANALYSIS PERFORMED Vegetable and fruit consumption and message awareness were measured using weighted-only and regression model-adjusted analyses to assess changes. RESULTS Mean vegetable and fruit consumption was significantly (P=.007) higher in 1997 than in 1991 using weighted-only analyses, but remained significant only for Hispanic (P=.03) and nonsmoker (P=.004) subgroups when adjusted for demographic shifts. Significantly higher percentages were found in the model-adjusted analyses for those consuming 5 or more (daily servings (23.4% to 25.8%), message awareness (7.7% to 19.2%), and knowledge of the 5 A Day Program (2.0% to 17.8%). APPLICATIONS/CONCLUSIONS A significantly positive change in vegetable and fruit consumption occurred between 1991 and 1997 according to traditional methods of survey data analysis, but null findings resulted when the data were adjusted for demographic shifts. Nutrition professionals should continue targeting specific demographic subgroups with tailored interventions to move all Americans toward achievement of dietary guidelines for vegetable and fruit consumption.

Baseline Fruit and Vegetable Intake among Adults in Seven 5 A Day Study Centers Located in Diverse Geographic Areas

OBJECTIVE To examine baseline rates of fruit and vegetable consumption among adults in the 5 A Day research trials in order to identify any regional and sociodemographic differences associated with daily servings. DESIGN The main outcome measure was the frequency of fruits and vegetables consumed within 1 month of the baseline survey as assessed by a 7-item food frequency questionnaire (FFQ). SUBJECTS/SETTING Participants (N = 15,060) were from 7 study centers. Study centers included schools (N = 48), worksites (N = 60), churches (N = 50), or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics (N = 15) in interventions to increase fruit and vegetable consumption. STATISTICAL ANALYSES Means and standard errors, adjusting for clusters, were calculated. A mixed linear model analyzed relationships between fruit and vegetable consumption and regional center, gender, age, race, education, income, marital status, food-shopping responsibility, and whether one lives with children. RESULTS Results indicate an overall mean intake of 3.6 daily servings of fruits and vegetables. Significant differences in mean daily servings were found among the regional study centers (low of 3.0 to high of 4.1). There were significant differences in mean daily consumption by age (< 30 years = 3.7 servings per day; 30 to 49 years = 3.4; > or = 50 years = 3.7), education (> high school = 3.4 servings per day; high school graduate = 3.4; some college = 3.5; college graduate = 3.9), race (black = 3.7 servings per day; Hispanic = 3.0; white = 3.6; other = 3.7), marital status (married = 3.6 servings per day; single = 3.5), and food-shopping responsibilities (little = 3.2 servings per day; about half = 3.6; most = 3.8). Only 17% of respondents ate 5 or more servings of fruits and vegetables per day. CONCLUSIONS The 7 regions showed significant variability in daily fruit and vegetable consumption, suggesting that a single national message to increase fruit and vegetable consumption may not reach the population segments most in need of changing. It is advisable to spend more time understanding the food consumption habits of the population under investigation to develop messages to foster behavior change.

Stages of Change for Increasing Fruit and Vegetable Consumption among Adults and Young Adults Participating in the National 5-a-Day for Better Health Community Studies:

Higher fruit and vegetable consumption is associated with a reduced risk of certain cancers and chronic diseases. The 5-a-Day for Better Health community studies are evaluating population-based strategies to achieving dietary behavior change using the stages-of-change model and associated theories. The authors present baseline comparisons of stages of change for fruit and vegetable consumption among adults and young adults in eight study sites representing diverse regions of the United States and diverse populations and settings. Three dominant stages, precontemplation, preparation, and maintenance, were found across sites. Women and those with college degrees were more likely to be in action/maintenance. Fruit and vegetable consumption, self-efficacy, and knowledge of the 5-a-Day recommendation were positively associated with more advanced stages of change in all study sites. The authors discuss the findings in relation to possible limitations of this and other dietary stages-of-change measures and suggest directions for future research.

Using food frequency questionnaires to estimate fruit and vegetable intake: Association between the number of questions and total intakes

Abstract The purpose of this study was to determine how estimates of fruit and vegetable intake, as determined from food frequency questionnaires, may be affected by the number of foods included. Three different national surveys of adults were used. Each of the surveys employed a food frequency questionnaire, but each included a different number of questions related to fruits and vegetables. Compared across surveys, values for median frequency of intake of individual fruits and vegetables were generally similar. However, values for median frequency of total fruit and vegetable intake, determined by summing across all fruits and vegetables included in the respective questionnaires, were very different and were associated with the number of questions asked: the 1987 National Health Interview Survey included 20 questions regarding fruits and vegetables, and the median frequency of intake was 23.8 times per week; the baseline survey for the national 5 A Day for Better Health Program included 33 questions, and the median intake was 34.6; and the 1982–1984 NHANES I Epidemiologic Follow-up Survey included 40 questions, and the median intake was 38.8. These findings suggest that summing across frequencies for individual foods may not be a valid way to assess intakes of total fruits and vegetables. Summary questions and/or adjustment factors may need to be employed to increase precision of the estimates.

A Randomized Clinical Trial Evaluating Online Interventions to Improve Fruit and Vegetable Consumption

OBJECTIVES We assessed change in fruit and vegetable intake in a population-based sample, comparing an online untailored program (arm 1) with a tailored behavioral intervention (arm 2) and with a tailored behavioral intervention plus motivational interviewing-based counseling via e-mail (arm 3). METHODS We conducted a randomized controlled intervention trial, enrolling members aged 21 to 65 years from 5 health plans in Seattle, Washington; Denver, Colorado; Minneapolis, Minnesota; Detroit, Michigan; and Atlanta, Georgia. Participants reported fruit and vegetable intake at baseline and at 3, 6, and 12 months. We assessed mean change in fruit and vegetable servings per day at 12 months after baseline, using a validated self-report fruit and vegetable food frequency questionnaire. RESULTS Of 2540 trial participants, 80% were followed up at 12 months. Overall baseline mean fruit and vegetable intake was 4.4 servings per day. Average servings increased by more than 2 servings across all study arms (P<.001), with the greatest increase (+2.8 servings) among participants of arm 3 (P=.05, compared with control). Overall program satisfaction was high. CONCLUSIONS This online nutritional intervention was well received, convenient, easy to disseminate, and associated with sustained dietary change. Such programs have promise as population-based dietary interventions.

Impact of Work Site Health Promotion on Stages of Dietary Change: The Working Well Trial

The stages of change construct has been applied to healthful dietary behavior in cross-sectional studies. This report examines associations of stages of change with diet prospectively and addresses whether (1) baseline stage of change predicts participation, (2) forward changes in stage movement were greater in treatment work sites, and (3) change in stage was associated with adoption of healthful diets, using data from a cohort of 11,237 employees. Findings indicate that persons in later stages of change reported higher participation levels. Employees from intervention work sites who were in preaction stages at baseline were much more likely to shift into action and maintenance stages than controls. Changes in dietary stage of change were associated with decreases in fat intake and increases in fiber, fruit and vegetable intake. Net change in diet due to the intervention was modest. Stage of change appears to be useful for understanding mediators of health promotion intervention effectiveness.

Outcomes from a School-based Nutrition Education Program Using Resource Teachers and Cross-disciplinary Models

Abstract The Integrated Nutrition Project is an ongoing comprehensive elementary school-based program focused on increasing consumption of whole grains, fruits, and vegetables in children and establishing nutrition education in the schools through local partnerships. This paper reports on years three and four outcomes. It was hypothesized that blending Social Cognitive Theory with the educational philosophies of Piaget and Dewey would enhance behavior change. The primary intervention consisted of (1) 24 weekly hands-on activities taught by a resource teacher and (2) six parent-taught lunchroom “mini-lessons.” Classroom activities were designed to reinforce concepts in math, science, literacy, and social studies. The quasi-experimental design used classrooms in matched schools; 20 and 17 classes were in treatment and comparison conditions, respectively, in year four. Surveys, interviews, and lunchroom plate waste were used to assess children; teachers were interviewed. Students in treatment classrooms achieved significantly greater gains in knowledge and self-efficacy regarding food preparation and fruit and vegetable consumption and consumed 0.4 more National Cancer Institute equivalent servings of fruits and vegetables in the lunchroom. Teachers responded favorably to the resource teacher model and the hands-on approach. The projects outcomes were attributed to the interventions theory-based behavior change focus and the use of a resource teacher who ensured consistent delivery of the intervention. Program implications include the need to explore variations of the resource teacher model and the potential for implementation on a larger scale.

A Randomized Controlled Trial of Multiple Tailored Messages for Smoking Cessation Among Callers to the Cancer Information Service

ABSTRACT Self-help materials computer-tailored to the specific needs of smokers have shown promise as a high-reach, low-cost intervention for smoking cessation. Adding tailored cessation materials to telephone-based cessation counseling may be a way of generating greater efficacy in promoting and maintaining cessation. The objective of this study is to assess the efficacy of adding different types of behavioral smoking cessation materials to brief telephone-based cessation counseling. A total of 1,978 smokers calling the National Cancer Institutes (NCIs) Cancer Information Service (CIS) for help in quitting smoking initially received brief cognitive–behavioral cessation counseling from a CIS information specialist. Following a baseline interview administered by the information specialist, subjects were randomly assigned to one of four conditions, each delivered by U.S. mail: a single, untailored smoking cessation guide (SU); a single, tailored smoking cessation guide (ST); a series of four (multiple) printed materials tailored only to baseline data (MT); and a series of four (multiple) printed materials tailored to baseline as well as retailored using 5-month interim progress data (MRT). The primary outcome measure was 7-day point prevalence abstinence rates assessed using a computer-assisted telephone interview (CATI) at 12-month follow-up. At 12-month follow-up, using intent-to-treat, imputed, and per-protocol analyses, no differences were found among the four experimental conditions (linear trend), or when the ST, MT, and MRT groups were compared with the control (SU) group. Participants in the two multiple message group conditions combined (MT + MRT), however, had significantly higher abstinence rates than participants in the two single message group conditions combined (SU + ST). Moreover, among subjects who reported quitting at the 5-month follow-up, participants receiving the MRT materials reported higher abstinence rates at 12 months than the other three groups combined (SU + ST + MT). The results of this study support the effectiveness, over and above a single telecounseling interaction, of multiple tailored print material contacts on cessation. These effects, however may be due to tailoring, or the longitudinal nature of the two multiple tailored conditions, or both. The strongest evidence for tailoring occurred in the MRT condition for relapse prevention, suggesting that print materials tailored to interim progress may be especially effective in this context. The qualities of specific psychosocial and communication elements in tailored materials should receive attention in future research.