Nutrition Education: Enhancing Effectiveness Isobel Contento, PhD, CDN

1. Nutrition Education: Enhancing Effectiveness Isobel Contento, PhD, CDN Teachers College Columbia University Association of State Nutrition Network Administrators February 16, 2010

2. Key elements of effectiveness, 1995 • • Focuses on specific behaviors, actions, practices • Uses communications and educational strategies to enhance awareness and motivation • Employs a systematic behavioral change process, including social support and empowerment • Includes environmental interventions and community activation & organization. Contento et al. 1995

3. Key elements of effectiveness • • Focuses on specific behaviors, actions, practices • Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

4. Key elements of effectiveness Focuses on specific behaviors, actions, practices • Eat fruits and vegetables, whole grains and fat-free and low-fat milk products everyday • Balance caloric intake from food and beverages and energy expenditure • Be physically active as part of a healthy lifestyle Core Behaviors for SNAP-Ed

5. Key elements of effectiveness • • Focuses on specific behaviors, actions, practices • Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

6. Pre-1995: knowledge based programs Moderators (SES, etc) Intervention Knowledge Behavior Source: Figures modified from Baranowski, 2007

7. Nutrition education as defined in SNAP-Ed guidance plan: Nutrition education is a set of learning experiences designed to facilitate the voluntary adoption of eating and other nutrition related behaviors conducive to health and well-being for those on a limited budget.

8. Learning experiences: A learning experience is the interaction between learners and external conditions through which learning takes place. Learning takes place through the active behavior of learners. [Not information dissemination per se]

9. Learning experiences: Education is what we do [from Latin : educare – to lead out; elicit; or evoke] Learning is what the program participants experience and accomplish

10. 1995-2005: Theory- based programs Intervention Moderators Psycho-social mediators Behavioral outcomes

11. Double mediation model Social / behavioral moderators Intervention Mediators Physiological moderators Behavioral Outcomes Health outcomes Health outcomes from behavior change programs Baranowski, SNE 2007

12. What contributes to effective nutrition education? Studies with adults

13. Is nutrition education effective? F&V IntakeFat Intake (22 studies) (79 studies) Meta-analysis na ** Differences in deltas ** ** Significant or not 17/22 68/79 Average intake 0.6 servings 7.3%fat calories 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)

14. Elements of effectiveness • Intervention characteristics: • Theoretical basis • Family components • Social support • Small groups* • Goal setting/self-monitoring/feedback* • Food-related activities • Cultural specificity • Study quality NCI Report, 2001 Ammerman 2002

15. Is nutrition education effective? (F&V) Pomerleau Lock, Knai McKee, J Nutr 2005

16. Studies with children

17. School-based F&V interventions

18. School-based F&V interventions Howerton JNEB 2007;39:186-196

19. Effective Mediators in Youth • Outcome expectations (or beliefs about outcomes): motivation • Self-efficacy: behavior change knowledge and skills • Habit Cerin, Barnett, Baranowski, JNEB, 2009

20. Key elements of effectiveness • • Focuses on specific behaviors, actions, practices • Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

21. Stepwise Procedure for Planning Theory-Based Nutrition Education Issues /concerns 1 major issue Inputs Step 1 Behaviors A few behaviors Step 1 Determinants /mediators Mediators for behavior change Step 2 Outputs Theory Theory model Step 3 Objectives Step 4 Objectives for mediators Activities/ Procedures Activities/procedures for mediators Step 5 Outcomes Evaluation for mediators & outcomes Evaluation Step 6 Contento, 2007

22. Stepwise Procedure for Planning Theory-Based Nutrition Education Issues /concerns 1 or a few related major issue(s) Inputs Step 1 Step 1 Behaviors Clearly defined behaviors for audience Step 2 Determinants /mediators Mediators specific for behaviors for given audience Outputs Theory Step 3 Theory model based on evidence for behavior for given audience Objectives Step 4 Clearly stated objectives for mediators Step 5 Activities/ Procedures Specific activities/ procedures for mediators Outcomes Evaluation for mediators & outcomes Step 6 Evaluation

23. Key elements of effectiveness • • Focuses on specific behaviors, actions, practices • Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

24. Multiple mediation model Parent education Moderating variables Parent mediators 50% 25% Parent behaviors Home environment 6.25% 12.5% Child Psycho-socials Child behaviors Child health outcomes Family based programs 3.13% Baranowski, SNE 2007

25. Multiple mediation model Parent education Other actions Parent mediators Parent behaviors Home environment Child Psycho-socials Child behaviors Child health outcomes Family based programs

26. . Social /Environmental Determinants: Person-Related Determinants Physical/ built environment • • Food availability • Built environment Experience with Food: Associative conditioning Intra-person factors • Social/ cultural • environment: • Social relations • Cultural practices • Social structures • Public policy • Biologically • determined • behavioral • predispositions: • Taste/pleasure • Sweet, sour, salt, bitter • Hunger/satiety mechanisms • Sensory specific satiety • Perceptions • Attitudes • Beliefs • 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: • Social affective • context • Parenting practices Inter-person factors Informational environment Family & social networks •Advertising •Media FOOD CHOICE AND DIET-RELATED BEHAVIORS Nutrition Education

27. Research Research is currently VERY active on the role of the environment. • Advances in understanding neighborhood food environments and socioeconomic inequalities in diet • Relationship between physical environment and physical activity in Europe • Fast food and food stores: differential density and impact on dietary intake and weight outcomes • Effect of price discounts and tailored education on supermarket food purchases: the Supermarket Healthy Options (SHOP) trial results (Ni Mhurchu, AJCN, 2010)

28. Theory-Based + Social-Ecological Approach Intervention Policy/ Environment Psycho- social mediators Moderators Biology & food experience Behavioral outcomes Health outcomes

29. 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; • Nutrition education is delivered through multiple venues and involves activities at the individual, institutional, community, and policy levels.

30. Using Theory in Nutrition Education Motivational pre-action component: Why-to take action Action / maintenance component: How-to take action Environmental/ policy support component

31. Comprehensive approach • Individual-level activities • Environment /policy activities • Both are needed • • Cookshop: schools • • Shape Up Somerville: community-based participatory approach

32. Comprehensive approach: WHO • Curriculum on diet & physical activity • Supportive school environment /policies • A physical activity program • A parental component • Healthy food options WHO, 2009

33. Comprehensive & assets approach We want to create environment/ culture where the healthy choice is • Easy choice • Desired choice • Expected choice in low-income communities California’s “Champion for Change” assets approach

38. Conceptual Framework for Theory-Based Nutrition Education: A Logic Model Inputs/ Resources Outputs: Theory-Based Intervention Outcomes 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

39. Policy and systemsMi Policy and systems Social structures: Systems: Food & beverage industry Government and political structures Interpersonal level Settings Food system Institutional/ organizational level Community level Food assistance programs Social structures Workplaces Schools, Neighborhoods, grocery stores, restaurants, parks InterINterIn Policy Health care system Health care organiz-ations Interpersonal level Public policy Collective empowerment Family, peers, friends, health professionals Rules, Policies, informal structures Social roles & norms Social networks Social & cultural norms & practices Individual level Food preferences & enjoyment Beliefs, attitudes, values, Knowledge, Social and cultural norms Self-efficacy Agency/empowerment Media Nutrition Education

40. Overlapping Roles Nutrition Education Health Promotion Education Non-nutrition health concerns Other food concerns Food availability; policy, systems, and social structures Public health nutrition

41. Overlapping Roles of Nutrition Education

42. Collaboration • Some funders will support only environmental /policy change • Others only direct nutrition education • Must collaborate – complement

43. Food Stamp Nutrition Education A rating of Results Not Demonstrated (RND) indicates that a program has not been able to develop acceptable performance goals or collect data to determine whether it is performing. There are no standardized performance measures across State programs to gauge progress. The scope of nutrition education efforts varies widely, making it difficult to establish meaningful outcome measures to capture the program's progress. While States collect some data on participation, the data collected is limited and ambiguous and varies across programs. http://www.whitehouse.gov/omb/expectmore/summary/10009031.2007.html

44. Evaluation –Best practices Controlled studies Currently being conducted Document effective practices Need to go beyond “success stories” • Effective: for whom • Effective: how exactly

45. Evaluation –Best practices Document effective practices for specific behaviors & strategies to generate “best practices.” For fruits and vegetables: Newsletters –design (theory framework); % reading & their reported use (outcome); how best delivered (procedure) Garden-based nutrition education - design (theory framework); outcome (mediators, behaviors); how best conducted (procedure) [Work groups]

46. Nutrition Education Logic ModelEvaluating Multiple Levels of Intervention Outputs Outcomes (Impacts) Inputs/ Resources Activities Participants 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 Identified audiences Learning & motivation Use skills, take action Use skills, take action Decreased disease risk Partners Organizational & community level (Partnerships & collaborations) Strategies to develop social support & partnerships Local agencies, organizations Increase awareness Commit to change Solve community problems Policy, systems & social structures (collaborations) Policy makers Create/ revise policy, change in systems, & social structures Policy makers Identify & define issues Work towards change Adopt/ revise policy