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Janicke DM, Lim CS, Perri MG, Mathews AE, Bobroff LB, Gurka MJ, Parish A, Brumback BA, Dumont-Driscoll M, Silverstein JH. Featured Article: Behavior Interventions Addressing Obesity in Rural Settings: The E-FLIP for Kids Trial. J Pediatr Psychol 2020; 44:889-901. [PMID: 31039250 DOI: 10.1093/jpepsy/jsz029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 03/04/2019] [Accepted: 04/08/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of behavioral parent-only (PO) and family-based (FB) interventions on child weight, dietary intake, glycated hemoglobin, and quality of life in rural settings. METHODS This study was a three-armed, randomized controlled trial. Participants were children (age 8-12 years) with overweight or obesity and their parents. A FB (n = 88), a PO (n = 78) and a health education condition (HEC) (n = 83) each included 20 group contacts over 1 year. Assessment and treatment contacts occurred at Cooperative Extension Service offices. The main outcome was change in child body mass index z-score (BMIz) from baseline to year 2. RESULTS Parents in all conditions reported high treatment satisfaction (mean of 3.5 or higher on a 4-point scale). A linear mixed model analysis of change in child BMIz from baseline to year 1 and year 2 found that there were no significant group by time differences in child BMIz (year 2 change in BMIz for FB = -0.03 [-0.1, 0.04], PO = -0.01 [-0.08, 0.06], and HEC = -0.09 [-0.15, -0.02]). While mean attendance across conditions was satisfactory during months 1-4 (69%), it dropped during the maintenance phase (42%). High attendance for the PO intervention was related to greater changes in child BMIz (p < .02). Numerous barriers to participation were reported. CONCLUSION Many barriers exist that inhibit regular attendance at in-person contacts for many families. Innovative delivery strategies are needed that balance treatment intensity with feasibility and acceptability to families and providers to facilitate broad dissemination in underserved rural settings.ClinicalTrials.gov Identifier: NCT01820338.
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Perri MG, Shankar MN, Daniels MJ, Durning PE, Ross KM, Limacher MC, Janicke DM, Martin AD, Dhara K, Bobroff LB, Radcliff TA, Befort CA. Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e206764. [PMID: 32539150 PMCID: PMC7296388 DOI: 10.1001/jamanetworkopen.2020.6764] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities. OBJECTIVE To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019. INTERVENTIONS Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss. MAIN OUTCOMES AND MEASURES The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up. RESULTS Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02054624.
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Affiliation(s)
- Michael G. Perri
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - Meena N. Shankar
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | | | - Patricia E. Durning
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - Kathryn M. Ross
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | | | - David M. Janicke
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - A. Daniel Martin
- Department of Physical Therapy, University of Florida, Gainesville
| | - Kumaresh Dhara
- Department of Statistics, University of Florida, Gainesville
| | - Linda B. Bobroff
- Department of Family, Youth, and Community Sciences, University of Florida, Gainesville
| | - Tiffany A. Radcliff
- Department of Health Policy and Management, Texas A&M University, College Station
| | - Christie A. Befort
- Department of Population Health, University of Kansas Medical Center, Kansas City
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Radcliff TA, Côté MJ, Whittington MD, Daniels MJ, Bobroff LB, Janicke DM, Perri MG. Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas. J Acad Nutr Diet 2020; 120:1163-1171. [PMID: 31899170 DOI: 10.1016/j.jand.2019.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/28/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention. OBJECTIVE This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas. DESIGN A cost-utility analysis was conducted. PARTICIPANTS/SETTING Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy. INTERVENTION Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status. MAIN OUTCOME MEASURES T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator. STATISTICAL ANALYSES PERFORMED Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation. RESULTS All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored. CONCLUSIONS Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.
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Perri MG, Limacher MC, von Castel-Roberts K, Daniels MJ, Durning PE, Janicke DM, Bobroff LB, Radcliff TA, Milsom VA, Kim C, Martin AD. Comparative effectiveness of three doses of weight-loss counseling: two-year findings from the rural LITE trial. Obesity (Silver Spring) 2014; 22:2293-300. [PMID: 25376396 PMCID: PMC4225635 DOI: 10.1002/oby.20832] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/18/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effects and costs of three doses of behavioral weight-loss treatment delivered via Cooperative Extension Offices in rural communities. METHODS Obese adults (N = 612) were randomly assigned to low, moderate, or high doses of behavioral treatment (i.e., 16, 32, or 48 sessions over two years) or to a control condition that received nutrition education without instruction in behavior modification strategies. RESULTS Two-year mean reductions in initial body weight were 2.9% (95% Credible Interval = 1.7-4.3), 3.5% (2.0-4.8), 6.7% (5.3-7.9), and 6.8% (5.5-8.1) for the control, low-, moderate-, and high-dose conditions, respectively. The moderate-dose treatment produced weight losses similar to the high-dose condition and significantly larger than the low-dose and control conditions (posterior probability > 0.996). The percentages of participants who achieved weight reductions ≥ 5% at two years were significantly higher in the moderate-dose (58%) and high-dose (58%) conditions compared with low-dose (43%) and control (40%) conditions (posterior probability > 0.996). Cost-effectiveness analyses favored the moderate-dose treatment over all other conditions. CONCLUSIONS A moderate dose of behavioral treatment produced two-year weight reductions comparable to high-dose treatment but at a lower cost. These findings have important policy implications for the dissemination of weight-loss interventions into communities with limited resources.
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Affiliation(s)
- Michael G. Perri
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | | | - Kristina von Castel-Roberts
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Michael J. Daniels
- Department of Statistics & Data Sciences and Department of Integrative Biology, University of Texas at Austin
| | - Patricia E. Durning
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - David M. Janicke
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Linda B. Bobroff
- Department of Family, Youth and Community Sciences, University of Florida Institute of Food and Agricultural Sciences
| | | | - Vanessa A. Milsom
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Chanmin Kim
- Department of Statistics & Data Sciences and Department of Integrative Biology, University of Texas at Austin
| | - A. Daniel Martin
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions
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Radcliff TA, Bobroff LB, Lutes LD, Durning PE, Daniels MJ, Limacher MC, Janicke DM, Martin AD, Perri MG. Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings. J Acad Nutr Diet 2012; 112:1363-1373. [PMID: 22818246 PMCID: PMC3432696 DOI: 10.1016/j.jand.2012.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 04/24/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND A major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources. OBJECTIVE This study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program. DESIGN We conducted a 1-year prospective randomized controlled clinical trial. PARTICIPANTS/SETTING The study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007. INTERVENTION The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74). MAIN OUTCOME MEASURES Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample. STATISTICAL ANALYSES PERFORMED Nonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance. RESULTS Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control). CONCLUSIONS Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.
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Affiliation(s)
- Tiffany A. Radcliff
- Department of Family Medicine, University of Colorado Denver, Mail Stop F413, P.O. Box 6508, Aurora, CO 80045-0508 (during study and present); Department of Health Policy and Management, Texas A&M Health Science Center, School of Rural Public Health, MS 1266, College Station, TX 77843-1266. (present) , tel. 979-862-7821, fax: 979-458-0656
| | - Linda B. Bobroff
- Department of Food and Nutrition, IFAS, University of Florida, 3026-B McCarty Hall D PO BOX 110310, Gainesville, FL 32611-0310 , tel. 352-273-3521 fax: 352-392-8196
| | - Lesley D. Lutes
- Department of Psychology, East Carolina University, 104 Rawl Building, Greenville, NC 27858-4353 , tel. 252-328-6283
| | - Patricia E. Durning
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, P.O. Box 10065, Gainesvillve, FL 32610 , tel. 352-273-6037, fax: 352-273-6199
| | - Michael J. Daniels
- Department of Statistics, 102 Griffin-Floyd Hall, P.O. Box 118545 Gainesville, FL 32611-8545, , tel. 352-273-1845, fax: 352-392-5175
| | - Marian C. Limacher
- Division of Cardiiovascular Medicine, School of Medicine, University of Florida, PO Box 100277, Room M-409 Gainesville, FL 32611-0277, , tel.: 352-846-1228, fax: 352-846-1217
| | - David M. Janicke
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, P.O. Box 10065, Gainesvillve, FL 32610 , tel. 352-273-6046, fax: (352) 273-6156
| | - A. Daniel Martin
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, P.O. Box 100154, Gainesville, FL 32610 , tel. 352-273-6105, fax: 352-273-6109
| | - Michael G. Perri
- University of Florida, College of Public Health and Health Professions, 101 S. Newell Drive, Suite 4101, Gainesvillve, FL 32610 , tel. 352-273-6214, fax: 352-273-6199
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Bobroff LB, Minton E, Diehl DC, Diaz X, Keith M, Medina-Solorzano A, Gylfadottir UK. Evaluation of MyPlate mini‐poster for older Latino adults: MiPlato para Adultos Mayores. FASEB J 2012. [DOI: 10.1096/fasebj.26.1_supplement.245.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Linda B Bobroff
- Family, Youth & Community SciencesUniversity of FloridaGainesvilleFL
| | - Emily Minton
- Family, Youth & Community SciencesUniversity of FloridaGainesvilleFL
| | - David C Diehl
- Family, Youth & Community SciencesUniversity of FloridaGainesvilleFL
| | | | - Mary Keith
- Hillsborough County Extension ServiceSeffnerFL
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Shelnutt KP, Bobroff LB, Diehl DC. MyPyramid for Older Adults. J Nutr Educ Behav 2009; 41:300-302. [PMID: 19508937 DOI: 10.1016/j.jneb.2008.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/15/2008] [Accepted: 07/28/2008] [Indexed: 05/27/2023]
Affiliation(s)
- Karla P Shelnutt
- Department of Family, Youth, and Community Sciences, University of Florida, Gainesville, 32611, USA.
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Perri MG, Limacher MC, Durning PE, Janicke DM, Lutes LD, Bobroff LB, Dale MS, Daniels MJ, Radcliff TA, Martin AD. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med 2008; 168:2347-54. [PMID: 19029500 PMCID: PMC3772658 DOI: 10.1001/archinte.168.21.2347] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Rural counties in the United States have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than nonrural areas, yet the management of obesity in rural communities has received little attention from researchers. METHODS Obese women from rural communities who completed an initial 6-month weight-loss program at Cooperative Extension Service offices in 6 medically underserved rural counties (n = 234) were randomized to extended care or to an education control group. The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions via telephone or face to face. Control group participants received 26 biweekly newsletters containing weight-control advice. RESULTS Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face extended-care programs regained less weight (mean [SE], 1.2 [0.7] and 1.2 [0.6] kg, respectively) than those in the education control group (3.7 [0.7] kg; P = .03 and .02, respectively). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention. CONCLUSIONS Extended care delivered either by telephone or in face-to-face sessions improved the 1-year maintenance of lost weight compared with education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of adapting research for rural communities with limited access to preventive health services. Trial Registration clinicaltrials.gov Identifier: NCT00201006.
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Affiliation(s)
- Michael G Perri
- College of Public Health and Health Professions, University of Florida, 101 S Newell Dr, Ste 4101, Gainesville, FL 32610-0185, USA.
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Bobroff LB, Turner E, Weddle DO, Brake JH, Lieberman LS, Allen TB. Interactive Learning for Congregate Nutrition Site Nutrition Education. ACTA ACUST UNITED AC 2003; 23:81-93. [PMID: 14650554 DOI: 10.1300/j052v23n01_06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Older adults who participate in the Older Americans Act Title III-C Elderly Nutrition Program often are at moderate to high nutritional risk. Although nutrition education is a component of the Elderly Nutrition Program, there are numerous barriers to promoting behavior change in older adults. Nutrition education programs targeted to congregate nutrition site participants must address their unique nutritional needs, while engaging them in activities that promote learning and motivate them to make positive behavior changes. This paper describes a pilot study of a theory-driven, five-lesson educational module designed to promote healthful eating behaviors among congregate nutrition site participants through interactive learning.
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Affiliation(s)
- Linda B Bobroff
- Department of Family, Youth and Community Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville 32611-0310, USA.
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Abstract
A program titled Contemporary Concerns about Food and Health (CCFH) was developed by the Florida Cooperative Extension Service after research in five counties showed 30%-74% of 2,308 middle-aged citizens to have three or more characteristics that placed them at above-average risk for developing diseases such as cardiovascular disease, adult-onset diabetes, and cirrhosis. CCFH addressed the effects of dietary and other practices that contribute to such lifestyle-related diseases. This article describes the test of the effectiveness of this program in increasing participant knowledge about the causes and preventions of health risk and in motivating them to make healthful risk-reducing changes in their lifestyles. A comparison, four-group, quasi-experimental design was used to study the program in five counties. The four groups included (a) those who participated only in CCFH lessons; (b) lesson participants who had also completed a computerized healthrisk profile; (c) a random sample of persons who completed only the health profile; and (d) a control group randomly selected to match both groups of lesson participants closely in age, sex, race, and county of residence. Results showed that lesson participants knew the answers to a significantly greater number of knowledge items than did the comparison groups, and they reported making more, and more important, changes in their lifestyles for reducing their risks of developing health problems.
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