Stephen Havas

Final results of the Maryland WIC 5-A-day promotion program

OBJECTIVES This National Cancer Institute-funded study sought to increase fruit and vegetable consumption among women served by the WIC program in Maryland. METHODS Over a 2-year period, a multifaceted intervention program using a randomized crossover design sought to increase fruit and vegetable consumption at 16 WIC program sites in Baltimore City and 6 Maryland counties. Participants were surveyed at baseline, 2 months postintervention, and 1 year later. RESULTS Two months postintervention, mean daily consumption had increased by 0.56 +/- 0.11 servings in intervention participants and 0.13 +/- 0.07 servings in control participants (P = .002). Intervention participants also showed greater changes in stages of change, knowledge, attitudes, and self-efficacy. Changes in consumption were closely related to number of nutrition sessions attended, baseline stage of change, race, and education. One year later, mean consumption had increased by an additional 0.27 servings in both intervention and control participants. CONCLUSIONS Dietary changes to prevent cancer can be achieved and sustained in this hard-to-reach, low-income population. However, many obstacles must be overcome to achieve such changes.

Attitudes and behaviors related to fruits and vegetables among low-income women in the WIC program:

Abstract This article describes formative research conducted as part of a study aimed at increasing fruit and vegetable consumption among low-income women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Focus group discussions and central location intercept interviews were conducted with WIC participants to answer questions such as (1) What are their food shopping, preparation, and eating habits? (2) What perceptions do they have about fruits and vegetables? (3) What barriers do they face to increased consumption of fruits and vegetables? and (4) What motivations and messages might be effective in promoting increased consumption? Results indicated that these women, while generally responsible for food shopping and preparation, did not cook extensively.They reported many positive perceptions of fruits and vegetables, but also identified barriers to increasing consumption, including lack of availability, time and effort to prepare, and preference for other foods. Several implications for nutrition interventions were suggested. First, a key motivation for these women was being a good role model for their children, suggesting a persuasive appeal to use in interventions. Second, review of the womens current eating behaviors led to an identification of five specific behaviors that had the most potential for increasing overall consumption. Finally, the findings suggested ways in which nutrition interventions could address each of the barriers identified.

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.

Reducing the Public Health Burden From Elevated Blood Pressure Levels in the United States by Lowering Intake of Dietary Sodium

Elevated blood pressure levels are a major cause of heart disease and stroke. Healthy People 2010 established objectives to reduce mortality from these diseases by 20% and to reduce the major causal factors associated with these elevated levels, such as excess sodium intake. The American public consumes far more sodium than is needed, most of which is added by food manufacturers and restaurants. In November 2002, the American Public Health Association adopted a policy resolution calling for a 50% reduction in sodium in the nations food supply over the next 10 years. Such a reduction would greatly enhance the chances of attaining the Healthy People 2010 objectives and would save at least 150 000 lives annually. This issue warrants public health intervention.

Psychosocial factors and intervention-associated changes in those factors as correlates of change in fruit and vegetable consumption in the Maryland WIC 5 a day promotion program

This study sought to examine: (a) the relative effects of baseline demographic and psychosocial factors and an intensive nutritional intervention on changes in fruit and vegetable consumption in low-income, ethnically diverse women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in Maryland; (b) whether this intervention, designed to modify psychosocial factors associated with fruit and vegetable consumption, was successful in changing these factors; and (c) whether changes in these factors were associated with increased consumption. The same women from 15 WIC program sites were surveyed at baseline and postintervention 8 months later. Women randomized to the intervention group showed significantly greater mean change in self-efficacy, attitudes, social support, and knowledge of national consumption recommendations than control group women. Changes in all psychosocial factors were significantly associated with nutrition session attendance and increased consumption. In a hierarchical model, changes in these factors accounted for most of the intervention effect on increased consumption.

Final results of the Maryland WIC food for life program

BACKGROUND The few randomized community trials in middle-income populations that tried to modify multiple dietary risk factors for cancer only demonstrated small changes. This trial sought to decrease the percent of calories derived from fat and to increase fruit, vegetable, and fiber intake among low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Maryland. METHODS We conducted six-month intervention programs for 1055 women at ten WIC sites; 1011 women served as controls. Intervention participants were invited to five interactive nutrition sessions and were sent written materials. Controls received usual care. Women were surveyed at baseline, two months post intervention, and one year later. All analyses conducted used an intention-to-treat paradigm. RESULTS Mean differences (intervention-control) in change from baseline were for percent calories from fat -1.62 +/- 0.33% (P < 0.0001), for consumption of fruits and vegetables 0.40 +/- 0.11 servings (P = 0.0003), and for fiber intake 1.01 +/- 0.31 grams (P = 0.001). These differences in change were related in a dose-response relationship to the number of sessions women attended and remained significant one year post-intervention for the first two outcomes. CONCLUSIONS Multiple dietary improvements can be achieved in a low-income population with an effective, multi-faceted intervention program. The changes in this trial exceeded those in previous community trials conducted in higher SES populations.

The ACCORD Trial and Control of Blood Glucose Level in Type 2 Diabetes Mellitus: Time to Challenge Conventional Wisdom

T HE DECISION BY THE National Institutes of Health to discontinue the glucoselowering portion of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial unexpectedly after 3.5 years because of an increased mortality rate in those randomized to intensive treatment of high blood glucose level led to numerous stories in the mass media noting how experts in the field were stunned by the findings. Yet the results of this trial were predictable. For almost 40 years, there has been evidence that intensive lowering of glucose levels in patients with type 2 diabetes mellitus (DM) can lead to significant harm and has limited benefits. This raises the question of why so many clinicians neglected the accumulating evidence of harm and thereby got the issue of treating type 2 DM so wrong. This Commentary will seek to provide some answers to that question and to provide lessons to be learned from this experience.

Mediation of Adult Fruit and Vegetable Consumption in the National 5 A Day for Better Health Community Studies

BackgroundThe 5 A Day for Better Health community studies demonstrated in randomized trials the efficacy of population-based strategies to increase fruit and vegetable consumption in diverse geographic areas and settings.PurposeMediation analysis can help to elucidate the theoretical basis of changing dietary habits. This is important for informing more powerful cancer prevention and control interventions to achieve broad public health impact.MethodsFive sites that focused on adults were included in mediation analyses to determine whether theoretically derived constructs assessed at baseline and follow-up contributed to explaining change in fruit and vegetable (F&V) consumption. These variables were knowledge, self-efficacy, and autonomy/responsibility. Stage of change also was considered as a potential moderating variable.ResultsSelf-efficacy and knowledge of the 5 A Day recommendation increased in those who received the interventions and were positively associated with higher F&V. Mediation of intervention effect was demonstrated for these variables. Autonomy/responsibility did not meet the criteria for mediation. There was no evidence of differential effect of mediators according to baseline stage.ConclusionsThe present study findings provide strong support for mediation of F&V consumption by two variables: self-efficacy and knowledge. The authors discuss the findings in relation to study limitations and future research directions.

The Effect of the Maryland WIC 5-a-Day Promotion Program on Participants’ Stages of Change for Fruit and Vegetable Consumption

The Maryland Women, Infants and Children (WIC) 5-A-Day Promotion Program examined the effect of a multifaceted nutrition intervention on changing the fruit and vegetable consumption of low-income women in the WIC program in Maryland. The sample consisted of 3,122 participants (1,443 intervention and 1,679 control) with a mean age of 27.2. Fifty-six percent were Black/African American. This article focuses on the effect of the intervention on the stages of change of the participants. Intervention participants showed significantly greater positive movement through the stages than control participants. Stages of change were measured for two specific target behaviors: eating five servings of fruits and vegetables a day and eating more servings of fruit and vegetables a day. Results demonstrated significant differences in the stage status of intervention and control women and in movement through the stages. The effectiveness of the intervention across groups depended on which staging measure was used.

Factors associated with attendance in a voluntary nutrition education program

Purpose. This paper examines factors associated with attendance in a National Cancer Institute-funded randomized trial of nutrition education to increase fruit and vegetable consumption among women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Setting. The study took place at 16 WIC sites in Maryland. Subjects. The participants were 1528 women who were enrolled in WIC or who had children enrolled in WIC, were ≥18 years of age, and planned to continue enrollment at that WIC site for at least 6 months (68% of eligible women approached agreed to participate). Intervention. Women received personal invitations, letters, and telephone reminders from peer educators encouraging their attendance at three bimonthly nutrition sessions. Measures. Demographic data were collected in a baseline survey. Attendance data and telephone and address changes were also collected. The postintervention survey included a question regarding reasons for nonattendance. Focus groups were also held to ascertain reasons for attendance or nonattendance. Chi-square tests of trend and multiple logistic regression, adjusted for within-site correlation, were used in statistical analyses. Results. Fifty-four percent of enrollees attended at least one session. Multiple logistic regression analysis showed increased odds of attending with higher age, breast-feeding, and/or knowledge of the recommendation to eat five or more servings of fruits and vegetables daily. There were decreased odds of attending for pregnant women who already had children. There were nonsignificant trends toward decreased attendance among unmarried women compared with married women and among blacks compared with nonblacks. Reasons given for nonattendance included withdrawal from WIC, moving, conflicting activities, negative feelings about nutrition education, and lack of transportation or child care. Conclusions. The results suggest that numerous barriers hinder participation in nutrition programs aimed at low-income women. These barriers should be considered by health care professionals when planning intervention programs. Overcoming these barriers presents a major challenge.