Does Nutrition Education Produce Behavior Change?

Transcription

1 Does Nutrition Education Produce Behavior Change? Jamie Dollahite Nutritional Sciences, Cornell University June 29, /5/ /5/2016 1

2 Outline Introduction Nutrition education in USDA programs similarities and differences More recent, informative studies Experimental and quasi-experimental designs Program evaluation data (pre/post-education) Practice-based evidence Economic analyses Effect of variations in practice Limitations 2

3 Definition of Nutrition Education Any set of learning experiences designed to facilitate the voluntary adoption of eating and other nutritionrelated behaviors conducive to health and well-being. Contento, J Nutr Educ. 1995;27:279 Focus today Direct nutrition education that includes face-to-face interaction with participants Studies reporting change in nutrition-related behaviors 3

4 Does nutrition education produce behavior change? The major finding from this comprehensive review of interventions (227 studies) is that nutrition education works, in that it 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. Contento, et al. J Nutr Educ. 1995;27:

5 Does WIC nutrition education produce behavior change? Most reports were for total WIC program. 5 studies investigated direct nutrition education among adult pregnant women enrolled in WIC 5

6 WIC Studies Study Interventions Results Rosander & Sims 1981 Targeted attitudes about nutrition & health to improve diet Classes vs. none [+] Maternal diet quality Auerbach & Walburn 1987 Saunders & Carol 1988 Paige et al 1994 BF promotion Lactation consultant vs. none BF promotion Post-partum contact vs. none Hospital visit; Phone call; Group support class BF promotion Motivational video; peer counseling; both; none [+] BF duration [+] BF duration [+] BF duration in 3 Intervention groups vs. control (Ø) among interv. groups 6

7 Summary: Nutrition Education Strategies for Enhancing Motivation & Changing Behaviors 1. Use systematic behavioral change process. 2. Provide interpersonal & personalized counseling & education. 3. Include active participation in learning. 4. Incorporate social support via family and/or others in group. 5. Use empowerment approach that enhances perceived personal control. Contento et al. J Nutr Educ.1995;27:

8 Nutrition Education in USDA programs FNS WIC SNAP-Ed NIFA EFNEP 8

9 Participant Characteristics WIC SNAP-Ed EFNEP Target Audience Women, children < 185% FPL SNAP recipients OR eligibles (< 185% FPL) Low income families, youth Food Assistance Yes Not necessarily ot necessarily Demographics Income (% < FPL) 74% Not available 85% Receiving food assistance 100% 66% 78% Minorities 41% 25% 74% 9

10 National Program Guidelines for Nutrition Education WIC SNAP-Ed EFNEP Focus Dietary Guidelines for Americans Method In person Telephone Electronic - Internet, Computer-based In person Social media Social marketing In person Dose 2x / 6 month certification period 1+ sessions tremendous variability Series Minimum 6 classes Educator RD/professional nutritionist or paraprofessional Varies Paraprofessional from the community Evaluation Outputs Outcomes: BF + health data Outputs Outputs Self-reported behavioral outcomes 10

11 RCTs and Quasi-experimental Studies Study Participants Intervention Design Results Ikeda et al Eicher- Miller, et. al Dollahite, et al WIC n=152 Vietnamese immigrant women, non- English speaking SNAP-Ed Female, head HH (n=219) EFNEP Parents of young children (n=168) 6-8 wkly lessons in home 5 lessons: Nutrition; Food resource management 8 lessons: Nutrition; Food resource management; Food safety Non-random Pre/post Control: Delayed intervention RCT Pre/post Control: Delayed intervention RCT Pre/post + 8 wk longitudinal Control: Delayed intervention 24-hr recalls [+] > 1 serv/fd grp [+] recommended serv all fd grps [+] Ca, K, riboflavin, vit B 6 (Ø) Baseline [+] Food Security & Food Insufficiency (Ø) Baseline [+] Period 8 wks [+] Period 16 wks 7/5/

12 a b a b b b a a a a b b b b b a a a Reported behavior score ± SEM by practice at 8-week intervals for immediate education (IE) group and delayed education (DE) group. a,b Different superscripts indicate statistically different scores (p<.05) Dollahite, et. al. J Nutr Educ Behav. 2014;46:

13 Practice-based Evidence Studies based on program evaluation data Design: Pre-post with no comparison group Studies WIC Study (Ritchie) SNAP-Ed study comparing education + SNAP (Kaiser) 2 studies with longitudinal data EFNEP & SNAP-Ed (Wardlaw) SNAP-Ed (Dollahite unpublished) 3 EFNEP economic studies 13

14 California WIC Program Evaluation Participants Statewide random sample n=3000 Intervention 2 or 3 sessions over 6 mo: F/V, whole grains, low-fat milk Results (phone interviews baseline and 6 months later) Participant reported self & family consumption: Fruit, Vegetables, Whole grains; Replacement whole with low-fat milk Self-reported food frequency in past week NS Fruit, Vegetables Juice Ritchie, et al. J Nutr Educ Behav. 2010:42:S2-S10 14

15 California SNAP-Ed Program Evaluation Participants Cooperative Extension UC CalFresh Convenience sample n=3744 Intervention 4 classes: Nutrition & food resource management Results (pre/post & comparing behaviors + SNAP) 6 resource management behaviors in > 1 behavior by 39-54% of participants Linear regression: Running out of food end of month Interaction (p<.001) SNAP participation & post-pre behavior score Kaiser et. al. J Nutr Educ Behav. 2015;47:

16 EFNEP & SNAP-Ed Longitudinal Evidence Setting & Participants Wyoming Cent$ible Nutrition Program 493 participants from (46% response rate) Intervention 10 weekly classes focused on diet quality, food resource management, food safety Results (pre/post in person and 1-4 year followup mail survey) 18 item food behavior checklist Wardlaw & Baker. Forum Fam Consum Issues. 2012;17(2). 16

17 EFNEP & SNAP-Ed Longitudinal Evidence Wardlaw & Baker. Forum Fam Consum Issues. 2012;17(2). 17

18 Cost-benefit Studies in EFNEP 1. Participants savings in food costs 2. Estimated savings in avoiding or delaying health care costs and loss of productivity 3. Society s willingness to pay for quality adjusted life years 18

19 EFNEP Savings in Food Costs Setting & Participants Tennessee; n=371 Design RCT delayed intervention control group Grocery store receipts & records of expenditures Results (Nutrition behaviors + food costs grocery store receipts/records of expenditures) Nutrition behaviors & diet Food sufficiency Food costs: $10-20/mo saved vs. $5.50/mo more spent Net Present Value : EFNEP = $ Controls = Burney & Houghton J Am Diet Assoc. 2002;102: 39-45

20 EFNEP Estimated savings in health care costs New York State Methods Pre/post with epidemiological modeling approach Cost-effectiveness 245 QALYs saved, at $20,863/QALY Society s willingness to pay: $9:58:1:00 (sensitivity $1.44-$41.92:$1:00) Strict benefit to cost $0.82:$1.00 (sensitivity $0.08-$4.33:$1:00) Dollahite, Kenkel, Thompson. J Nutr Educ Behav. 2008;40:

21 EFNEP Estimated savings in health care costs Comparison of data from all states Methods Replicated Dollahite et al. CEA Cost-effectiveness Cost/QALY: Median = $22,904 + $16,394 Range = $7,389 - $101,695 the median All but 3 states < $50,000/QALY Baral, Davis, Blake, Serrano. J Nutr Educ Behav. 2013;45:

22 Does nutrition education produce behavior change? Yes, but many variables Effectiveness of intervention as designed Fidelity to intervention Educator s skill Dose Frequency of lessons 22

23 Limitations of the Evidence Difficulty of assessing dietary intake and related nutrition behaviors under the best of circumstances. Social desirability in responses Response shift bias 23

24 7/5/