Linda S. Boeckner

Internet-based Interventions Have Potential to Affect Short-term Mediators and Indicators of Dietary Behavior of Young Adults

OBJECTIVE Evaluate a theory-based, Internet-delivered nutrition education module. DESIGN Randomized, treatment-control design with pre-post intervention assessments. SETTING AND PARTICIPANTS Convenience sample of 160 young adults (aged 18-24) recruited by community educators in 4 states. Study completers (n = 96) included a mix of racial/ethnic groups and family demographics, but were predominately white females without children. INTERVENTION A Transtheoretical Model (TTM)-based, stage-tailored Internet program, F&V (Fruit & Vegetable) Express Bites, was delivered to treatment group participants; controls received nontailored messages in a comparable format. MAIN OUTCOME MEASURES AND ANALYSIS: TTM constructs at baseline, immediately postviewing, and at 30-day follow-up were compared via chi-square, McNemars test, and logistic regression. Qualitative use and acceptability indicators were collected postviewing (treatment only). RESULTS Of baseline respondents, 86.5% completed the study. At follow-up, self-efficacy, decisional balance, and selected processes improved for both groups, with only marginal advantages for the theory-based version. Fruit and vegetable consumption changes were similar for both groups. Qualitative measures of knowledge, confidence, and motivation improved (not measured for controls). Favorable ratings of treatment program acceptability and personal relevance were reported. CONCLUSIONS AND IMPLICATIONS The Internet is a favorable option for reaching young adults with nutrition messages. This study did not identify strong advantages of theory-based tailoring, especially for fruit consumption, which had weaker barriers than vegetable consumption among this target audience.

Use and Reliability of the World Wide Web Version of the Block Health Habits and History Questionnaire with Older Rural Women

OBJECTIVE To estimate the parallel forms reliability of the paper and pencil and World Wide Web versions of the 1998 Block Health Habits and History Questionnaire (HHHQ) and to examine the feasibility of older women using the Web version. DESIGN Within a 2-week period, participants completed both the paper and pencil and Web versions of the HHHQ and pre- and postsurveys about their comfort level and experience in using the computer. SUBJECTS A convenience sample of 31 white women, aged 58.2 6.3 years, from a rural location were recruited via direct mail, public service announcements, and public posters. VARIABLES MEASURED The parallel forms reliability of the HHHQ administered in two different ways and the perceptions of the women on their computer use were measured. ANALYSIS Dietary data were analyzed using Pearson correlations and paired t tests. Alpha significance level was set at P <or=.05. RESULTS The Web HHHQ had adequate reliability when compared with the paper and pencil version; paired sample correlations approximated acceptable coefficients (r >.70), with only vitamin C (r =.54) and iron (r =.65) falling below the acceptable standard. Eleven women indicated initial discomfort with the computer, but after the study, only three said they were uncomfortable completing the on-line survey. IMPLICATIONS Internet dietary assessment tools could be a feasible assessment tool for older women to self-administer.

Determinants of Older Rural Women’s Activity and Eating

This research examined the relationship of cognitive-perceptual determinants from the Health Promotion Model to physical activity and healthy eating at baseline of a clinical trial among rural women aged 50 to 69. Two multivariate regression analyses with canonical correlation (N = 179) each yielded one interpretable canonical variate that explained similar amounts of variance (21.7% and 22.5%) in sets of activity and eating variables. In both analyses, the determinants set is a linear combination of all four cognitive-perceptual constructs from the model (perceived self-efficacy, benefits, barriers, interpersonal influences). The activity behavior set included caloric expenditure, VO2max, and stretching and strengthening activity, whereas the eating behavior set included daily percentage of calories from fat and servings of fruits and vegetables, meat, and whole grains. As predicted by theory, greater self-efficacy, benefits and interpersonal support, and fewer barriers are associated with desirable healthy lifestyle behaviors.

Clinical trial of tailored activity and eating newsletters with older rural women

Background: Unhealthy diet and lack of physical activity increase rural midlife and older womens risk of chronic diseases and premature death, and they are behind urban residents in meeting Healthy People 2010 objectives. Objectives: The objective of this study was to compare a tailored intervention based on the Health Promotion Model with a generic intervention to increase physical activity and healthy eating among rural women. Methods: In a randomized-by-site, community-based, controlled, clinical trial, Wellness for Women, 225 women aged 50 to 69 years were recruited in two similar rural areas. Over 12 months, women received by mail either 18 generic newsletters or 18 newsletters computer tailored on Health Promotion Model behavior-specific cognitions (benefits, barriers, self-efficacy, and interpersonal support), activity, and eating. Outcomes at 6 and 12 months included behavioral markers and biomarkers of physical activity and eating. Data were analyzed by repeated-measures analysis of variance and chi-square tests (&agr; < .05). Results: Both groups significantly increased stretching and strengthening exercise and fruit and vegetable servings and decreased percentage of calories from fat, whereas only the tailored group increased moderate or greater intensity activity and decreased percentage of calories from saturated fat from baseline to 6 months. Both groups increased stretching and strengthening exercise, whereas only the tailored group increased moderate or greater intensity activity and fruit and vegetable servings and decreased percentage of calories from fat from baseline to 12 months. Both groups had several changes in biomarkers over the study. A higher proportion of women receiving tailored newsletters met Healthy People 2010 criteria for moderate or greater intensity activity, fruit and vegetable servings, and percentage of calories from fat at 12 months. Discussion: Mailed computer-tailored and generic print newsletters facilitated the adoption of change in both activity and eating over 6 months. Tailored newsletters were more efficacious in facilitating change over 12 months.

Feasibility of Internet-delivered weight loss interventions among rural women ages 50-69.

Purpose: The increased availability and use of the Internet by midlife and older women who seek health information may provide an innovative method for delivering weight loss interventions. This preliminary study examined the feasibility and efficacy of web‐based interventions for promoting weight loss among rural overweight and obese women ages 50‐69 (M =55.5 ± 4.9) over a 3‐month period. Methods: Twenty‐one Caucasian women with body mass index of 28‐34.5 (M = 30.69 ± 2.58) were randomly assigned to either a Web site only or Web site augmented with a peer‐led support group. The Web site included recommended approaches to healthy eating and activity, weekly newsletters, and other resources. Body weight, eating, and activity measures were assessed at baseline and postintervention. Data analysis included 2‐way repeated measures ANOVAs with effect sizes reported as appropriate for a pilot study. Results: Sixteen women (76.2%) completed the study; 14 lost from 2% to 10% of their body weight, and 2 gained 2% of their weight. Large effect sizes were found over time for body weight, estimated VO2max, and percentage of calories from fat. For time by group interaction, large effect sizes favoring the Web site plus peer‐led support group were found for body weight, waist circumference, percent body fat, whole grain servings, and both systolic and diastolic blood pressure. Process evaluations indicated that 85.7% of women accessed the Web site weekly. There were a total of 305 hits in the Web site only group versus 658 hits in the peer‐led support groups. Conclusions: Internet delivered interventions appeared feasible for these rural women with weight loss and improvement in selected eating and activity measures after 3 months.

Maintenance of activity and eating change after a clinical trial of tailored newsletters with older rural women.

Background:In the Wellness for Women Project, a randomized-by-site 1-year controlled clinical trial, the efficacy of generic newsletters and newsletters tailored on Health Promotion Model behavior-specific cognitions, eating behavior, and activity behavior were compared among 225 women aged 50 to 69 years. Objectives:The purpose of this study was to compare the maintenance of change in healthy eating and physical activity over the 12 months following the tailored versus generic mailed newsletter intervention. Methods:Outcomes at 18 and 24 months included behavioral markers and biomarkers of physical activity and eating. Data were analyzed using the multivariate approach to repeated measures analysis of variance and generalized estimating equations (α <.05). Results:At 18 months, the tailored group maintained levels of all eating and activity behaviors, whereas the generic group maintained levels of fruit and vegetable servings, a moderate or greater activity, stretching exercise, lower body strength and flexibility but increased saturated fat intake and declined in weekly strength exercise and cardiorespiratory fitness. At 24 months, both groups maintained or returned to 12-month levels of all eating behaviors,moderate or greater activity, stretching exercise, and flexibility but declined in cardiorespiratory fitness; the tailored group maintained levels of strength exercise and lower body strength, whereas the generic group decreased in both. A greater proportion of women who received tailored newsletters continued to achieve most Healthy People 2010 criteria for eating and activity. Discussion:Mailed tailored print newsletters were more efficacious than generic newsletters in facilitating maintenance of change in eating and activity for 6 months postintervention. Both tailored and generic newsletters facilitated the maintenance of change in eating behaviors and in moderate or greater physical activity and stretching exercise, whereas tailored newsletters were more efficacious in maintaining change in strength exercise for 12 months postintervention.

Effectiveness of tailored lifestyle interventions, using web-based and print-mail, for reducing blood pressure among rural women with prehypertension: main results of the Wellness for Women: DASHing towards Health clinical trial

BackgroundLifestyle modification is recommended for management of prehypertension, yet finding effective interventions to reach rural women is a public health challenge. This community-based clinical trial compared the effectiveness of standard advice to two multi-component theory-based tailored interventions, using web-based or print-mailed delivery, in reducing blood pressure among rural women, ages 40–69, with prehypertension.Methods289 women with prehypertension enrolled in the Wellness for Women: DASHing towards Health trial, a 12-month intervention with 12-month follow-up. Women were randomly assigned to groups using a 1:2:2 ratio, comparing standard advice (30-minute counseling session) to two interventions (two 2-hour counseling sessions, 5 phone goal-setting sessions, strength-training video, and 16 tailored newsletters, web-based or print-mailed). Linear mixed model methods were used to test planned pairwise comparisons of marginal mean change in blood pressure, healthy eating and activity, adjusted for age and baseline level. General estimating equations were used to examine the proportion of women achieving normotensive status and meeting health outcome criteria for eating and activity.ResultsMean blood pressure reduction ranged from 3.8 (SD = 9.8) mm Hg to 8.1 (SD = 10.4) mm Hg. The 24-month estimated marginal proportions of women achieving normotensive status were 47% for web-based, and 39% for both print-mailed and standard advice groups, with no group differences (p = .11 and p = .09, respectively). Web-based and print-mailed groups improved more than standard advice group for waist circumference (p = .017 and p = .016, respectively); % daily calories from fat (p = .018 and p = .030) and saturated fat (p = .049 and p = .013); daily servings of fruit and vegetables (p = .008 and p < .005); and low fat dairy (p < .001 and p = .002). Greater improvements were observed in web-based versus standard advice groups in systolic blood pressure (p = .048) and estimated VO2max (p = .037). Dropout rates were 6% by 6-months, 11.4% by 24 months, with no differences across groups.ConclusionsRural women with prehypertension receiving distance-delivery theory-based lifestyle modifications can achieve a reduction of blood pressure and attainment of normotensive status.Trial registrationClinicalTrials.gov NCT00580528

Web-based interventions for weight loss and weight maintenance among rural midlife and older women: protocol for a randomized controlled trial

BackgroundWeight loss is challenging and maintenance of weight loss is problematic among midlife and older rural women. Finding effective interventions using innovative delivery methods that can reach underserved and vulnerable populations of overweight and obese rural women is a public health challenge.Methods/DesignThis Women Weigh-In for Wellness (The WWW study) randomized-controlled trial is designed to compare the effectiveness of theory-based behavior-change interventions using (1) website only, (2) website with peer-led support, or (3) website with professional email-counseling to facilitate initial weight loss (baseline to 6 months), guided continuing weight loss and maintenance (7-18 months) and self-directed weight maintenance (19-30 months) among rural women ages 45-69 with a BMI of 28-45. Recruitment efforts using local media will target 306 rural women who live within driving distance of a community college site where assessments will be conducted at baseline, 3, 6, 12, 18, 24 and 30 months by research nurses blinded to group assignments. Primary outcomes include changes in body weight, % weight loss, and eating and activity behavioral and biomarkers from baseline to each subsequent assessment. Secondary outcomes will be percentage of women achieving at least 5% and 10% weight loss without regain from baseline to 6, 18, and 30 months and achieving healthy eating and activity targets. Data analysis will use generalized estimating equations to analyze average change across groups and group differences in proportion of participants achieving target weight loss levels.DiscussionThe Women Weigh-In for Wellness study compares innovative web-based alternatives for providing lifestyle behavior-change interventions for promoting weight loss and weight maintenance among rural women. If effective, such interventions would offer potential for reducing overweight and obesity among a vulnerable, hard-to-reach, population of rural women.Trial RegistrationClinicalTrials.gov: NCT01307644

Associations of Cardiorespiratory Fitness and Fatness with Metabolic Syndrome in Rural Women with Prehypertension

Background. This study investigated the associations of fitness and fatness with metabolic syndrome in rural women, part of a recognized US health disparities group. Methods. Fitness, percentage body fat, BMI, and metabolic syndrome criteria were assessed at baseline in 289 rural women with prehypertension, ages 40–69, enrolled in a healthy eating and activity community-based clinical trial for reducing blood pressure. Results. Ninety (31%) women had metabolic syndrome, of which 70% were obese by BMI (≥30 kg/m2), 100% by percentage body fat (≥30%), and 100% by revised BMI standards (≥25 kg/m2) cited in current literature. Hierarchical logistic regression models, adjusted for age, income, and education, revealed that higher percentage body fat (P < 0.001) was associated with greater prevalence of metabolic syndrome. Alone, higher fitness lowered the odds of metabolic syndrome by 7% (P < 0.001), but it did not lower the odds significantly beyond the effects of body fat. When dichotomized into “fit” and “unfit” groups, women categorized as “fat” had lower odds of metabolic syndrome if they were “fit” by 75% and 59%, for percentage body fat and revised BMI, respectively. Conclusion. Among rural women with prehypertension, obesity and fitness were associated with metabolic syndrome. Obesity defined as ≥25 kg/m2 produced results more consistent with percentage body fat as compared to the ≥30 kg/m2 definition.

Low-income young adults report increased variety in fruit and vegetable intake after a stage-tailored intervention

The objective of this study was to determine if a fruit and vegetable (FV) intervention, previously demonstrated to increase amount of FV per day, also increased the variety consumed. Variety in FV intake was assessed using a 26-item FV (12 fruit and 14 vegetable) food frequency questionnaire on 1255 low-income adults, with ages from 18 to 24 years (control = 684 vs experimental = 571), after completion of a stage-tailored intervention to increase FV intakes. The food frequency questionnaire was administered at 12 months to assess how often and how much participants ate of each item over the previous year. Variety was defined as the number of different types of fruits and vegetables consumed. At completion, the experimental group vs the control group had significantly greater variety in number of fruit items (9.5 +/- 0.1 vs 9.1 +/- 0.1, P < or = .001) and vegetable items (11.5 +/- 0.1 vs 11.2 +/- 0.1, P < .01) as well as greater total intake of fruits (2.73 +/- 0.09 vs 2.33 +/- 0.11 cups, P < .01) and vegetables (1.87 +/- 0.10 vs 1.62 +/- 0.01 cups, P < or = .001) and a greater consumption of the categories of seasonal fruits (P < .05), juices (P < .01), and high-beta-carotene vegetables (P < or = .001). This is one of the first studies to document an increase in FV variety as a result of an educational intervention for low-income young adults.