- Email: [email protected]
Applying PRECEDE-PROCEED to Develop an Intuitive Eating Nondieting Approach to Weight Management Pilot Program
Research Brief Applying PRECEDE-PROCEED to Develop an Intuitive Eating Nondieting Approach to Weight Management Pilot Program Renee E. Cole, PhD, RD, LD1; Tanya Horacek, PhD, RD2 ABSTRACT Objective: To describe the use of a consolidated version of the PRECEDE-PROCEED participatory program planning model to collaboratively design an intuitive eating program with Fort Drum military spouses tailored to their readiness to reject the dieting mentality and make healthful lifestyle modifications. Design: A consolidated version of PRECEDE-PROCEED guided demographic, epidemiological, behavioral, organizational, and administrative diagnosis through survey research. Focus groups composed of planning/steering committee members diagnosed environmental, organizational, administrative. and policy considerations. Objectives were set for each phase to assist with program tailoring. Setting: Recruitment at Fort Drum Army Installation, NY, summer 2004. Participants: Ninety-one military health beneficiaries aged 20-65 years of age completed the pilot-tested survey packet. Phenomenon of Interest: The survey assessed quality of life issues, Diet Mentality, Healthy Eating Index, and Intuitive Eating Stages of Change scores, and desired program mix. Analysis: Mean and mode of survey responses and scores. Results: A 10-week ‘‘My Body Knows When’’ intuitive eating program was tailored to increase attendance, reduce barriers, and increase successful rejection of a dieting mentality. Conclusions and Implications: A consolidated version of PRECEDE-PROCEED efficiently guided participatory planning to tailor this program. Key Words: participatory planning, intuitive eating, nondieting, Stages of Change (J Nutr Educ Behav. 2009;41:120-126.)
INTRODUCTION The American Dietetic Association supports the concept of providing combined weight and lifestyle management interventions rather than focusing solely on weight loss alone.1 Weight management intervention goals should be to prevent weight gain, improve physical and emotional health, and move toward realistic weight loss goals achieved through sensible and tolerable eating and exer-
1
cise behaviors, while preventing use of unreasonable dieting techniques, tools, and behaviors that lead to a dieting mentality.1 It is estimated that 45 million Americans diet each year and spend $30 billion per year on their dieting efforts.2 Intuitive eating (IE) epitomizes the nondieting approach to weight management by reinforcing behavior change without focusing specifically on weight loss.3 Intuitive eating modifies current habits to incorporate
Outpatient Nutrition Clinic, Brooke Army Medical Center, Fort Sam Houston, TX (completed study as a doctoral student at Syracuse University, Syracuse, NY) 2 Dietetics Department of Nutrition and Hospitality Management, Syracuse University, Syracuse, NY This research was conducted at the Fort Drum Medical and Dental Activity Center, Fort Drum, New York, and the Department of Nutrition and Hospitality Management, College of Human Development, Syracuse University, Syracuse, New York. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the United States government. Address for correspondence: Renee E. Cole, Brooke Army Medical Center, 3851 Roger Brooke Dr, Fort Sam Houston, Texas 78234; Phone: (210) 916-3656; Fax: (210) 916-1991; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2008.03.006
120
healthful behaviors that support weight loss over time. To implement a successful IE program, tailoring the program to the population’s current readiness to make healthful behavior changes is important.4 Behavior change programs are often developed without adequate target population assessment. Participatory program planning allows for program tailoring by involving the target population in the design process to meet their needs and reduce their barriers for change.5-9 A model developed by Green and Kreuter,10 known as Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PRECEDEPROCEED) (P-P), is a health promotion planning model involving a detailed series of 9 steps or phases for the planning, implementation, and evaluation processes. Five PRECEDE phases identify priorities and objectives for a particular population. PROCEED phases provide criteria for policy, implementation, and
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009 evaluation. Typically each PRECEDE phase is performed individually and completed in sequence. The process can be time consuming, and adequate planning time is not always available to conduct the phases sequentially as originally intended. The purpose of this project was to use a consolidated version of the P-P model11-14 to design an IE program for Fort Drum military spouses in which intervention techniques focus on readiness to reject dieting mentality and make healthful lifestyle modifications. The results of the PROCEED evaluation of program effectiveness will be published separately.
METHODS Subjects Ninety-one military adult family members of the Fort Drum Army installation in Watertown, NY, aged 2065 years, volunteered for the study. Ninety-eight percent were married females with an average of 2 children. About 39% had a high school diploma or general educational diploma, 27% completed 2 years of college, and 34% had 4 years or more of college, and the annual average family income was between $25 000 and $50 000. The recruitment and consenting process was approved by the Syracuse University and Walter Reed Army Medical Center Institutional Review Boards.
Recruitment and Data Collection Procedure The program study was advertised over a 1.5-month time period through various Fort Drum media avenues. The advertisement asked for volunteers who were tired of dieting and would like to enjoy food without feeling guilty. Participants completed a survey packet with specific instructions, a consent form, received a small incentive for participating, and were given the opportunity to voluntarily participate in the intervention phase (the nondieting approach to weight management program).15
Model Design The P-P model was consolidated to diagnose the target population within
a shorter time period (outlined in Table 1).10 Demographic, epidemiological, behavioral, and organizational data were collected through the use of a single survey packet, not as distinct individual phases. Environmental, administrative and policy data were collected through focus groups composed of planning and steering committee members to capture additional PRECEDE diagnostic data, such as resources and funding availability, child care desires/options, and health care access/concerns. The planning committee, composed of medical facility management representatives, assisted in advertising and resource management and provided a network to overcome specific policy or administrative hurdles and improve program development. The steering committee, composed of volunteers from the target sample, met weekly prior to program start date and biweekly thereafter to provide their input on administrative hurdles faced.
Cole and Horacek 121 from BMI categories; BMI 18.5-24.9 depicts normal weight, BMI 25-29.9 depicts overweight, and BMI 30 and above depict obesity.1,26
Behavioral and educational measures. The Diet Mentality Scale score
The diagnostic data for each of the PRECEDE phases as listed in Table 1 were collected through the use of 5 surveys combined as 1 packet with the consent form and distributed at one time. The mean and mode of the survey questions provided the PRECEDE phase data to identify the most problematic areas requiring more attention to assist in development of the phase objectives and details for how to structure the program.
and Healthy Eating Index (HEI) score19 were selected to assess overall change in eating behaviors/attitudes to evaluate program effectiveness. The Diet Mentality Scale score was created for this study based on 33 survey questions16-18 (19 three-point and 14 five-point response questions) from the surveys noted in Table 1. Thus, 33 was the minimum and 127 was the maximum score. A score of 33 to 79 signified an intuitive eater and 80 to 127 as a dieter mentality. Questions focus on impact of food choices, self-image, self-efficacy, dieting habits, and physical activity habits. The mode and percentage of survey results will assist in program tailoring based on areas for IE improvement. A 3-day food record was completed, providing data to compute an overall HEI score. The HEI is based on a maximum of 100 points, with up to 10 points from each of 10 components: servings of grains, vegetables, fruits, milk, and meat, as well as total calories from fat, saturated fat from total fat calories, cholesterol, sodium, and food variety. For example, if 6 servings of grains are recommended and consumed, then 10 points were awarded. If 3 servings were consumed, then 5 points were awarded. If 0 servings were consumed, then 0 points were awarded.
Social measures focused on quality of life issues. An extensive list of life pri-
Educational and organizational measures. Unlike smoking, IE cannot
orities, stressors, and activity options, developed through pilot-testing, were provided with options for open comments in the Nutrition-Related Quality of Life Survey.
be defined by one distinct behavior, but it is a compilation of attitudes/behaviors relating to eating a variety of food, listening to hunger/fullness cues, and avoiding emotional eating. The Stages of Change for Pleasurable and Healthy Eating Habits Survey was used to determine participant Stage of Change (pre-contemplators, contemplators, preparers, taking action, in maintenance, or in the termination phase).17
Instruments, Data Processing, and Analysis
Epidemiological measures. Past and current medical conditions, body mass index (BMI, kg/m2), and weight were obtained at baseline data collection prior to complete analysis of survey data. Weight and height were measured with a validated electronic scale and stadiometer, respectively. Weight descriptions were determined
Organizational and administrative program mix. Various topics in
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122 Cole and Horacek
Table 1. PRECEDE-PROCEED Model Diagnostic Phases10 Diagnostic Phase Social
Epidemiological
Behavioral and environmental
Educational and organizational
Administrative and policy
PROCEED phases
Description Quality of life concerns and aspirations (social, economic, cultural, and environmental); top stressors, priorities, and activities enjoyed, support/pressure from family/friends, etc. Specific health goals and problems associated with quality of life issues identified; BMI, co-morbidities, other health conditions, etc. Specific health-related factors possibly linked to health problems identified. Target leisure activities (amount or frequency of physical activity, etc.), dietary habits (restrictive eating, emotional eating, past diets, diet tools, etc.), and attitudes toward weight loss and intuitive eating (importance of weight, weight management, self worth, etc.) Identify, sort, and categorize the predisposing, reinforcing, and enabling factors that influence health behaviors identified; dieting thoughts, following hunger/fullness cues, feelings about food choices, value of physical activity, ability to make healthful choices Budgetary and staff requirements and availability, barriers/limitations to overcome, and available policies to change or support Implementation, Evaluations – Process, Impact, Outcome
Assessment Method Open-ended questions plus Nutrition-Related Quality of Life Survey16
Retrospective History Survey and Anthropometric Measurements
Intuitive Eating Attitudes and Behaviors Survey,17 Dieting Mentality Quiz,18 Healthy Eating Index,19 3-day food records
Stages of Change for Pleasurable and Healthy Eating Habits Survey17
Focus group, Desired Program Mix Survey
Reported separately
PRECEDE-PROCEED indicates Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development; BMI, body mass index.
disease prevention, nutrition and weight management, physical activity, and program structure desired were included in the survey. Program mix options included preferred day and time for class, number and length of sessions, type of learning environment, incentives, and the desire for babysitting, educational pamphlets, and a class bulletin board. The specific PROCEED methods and results for the implementation and evaluation phases are reported elsewhere.15 The survey packet was pilot-tested by 20 noneligible representative spouses. The survey responses were tabulated to glean the following information: for appropriate responses, need for clarification, questions not
answered and why, and redundancy or inconsistencies.20 A revised survey packet was approved by the Syracuse University Nutrition Department and the Institution Review Boards from Syracuse University and Walter Reed Army Medical Center.
Social Diagnosis Priorities in life tended to center around family health, happiness, and financial stability. The top 2 stressors related to participants’ body image and ability to control weight. Identified objectives are reported in Table 2.
RESULTS Of 295 surveys distributed, 91 were returned and analyzed (31% response rate). Survey and focus group data collected for each phase of the PRECEDE diagnosis were used by investigators to develop the objectives, assist with program design and plan process, impact, and outcome evaluations.
Epidemiological Diagnosis Thirty percent of the health concerns revolved around common health indicators: high blood pressure, high blood cholesterol, and diabetes. Disease prevention education material was incorporated into the program.
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Table 2. PRECEDE Phase Objectives Identifieda Social diagnosis: 1. Improve self-image such that ‘‘current weight status’’ is no longer ranked within the top 5 life stressors. 2. Reduce the percentage of those who would feel happier if they lost weight from 90% to 80%. 3. Reduce the percentage of those who are unhappy with the way they look from 90% to 80%. 4. Improve ability to engage in physical activity such that ‘‘lack of physical activity’’ is no longer ranked in the top 5 life stressors. Epidemiological diagnosis: No BMI change is expected because of short program duration. Behavioral and environmental diagnosis: The behavioral objectives identified were: 1. Increase physical activity from 39% to 50% being active 30 minutes 3 times per week. 2. Increase the percentage abandoning restrictive diets from 13% to 25% through education. 3. Shift the mean Healthy Eating Index score from 65 to 72 by the end of the program. 4. Shift the mean Diet Mentality score from 82 to 74 by the end of the program. The environmental objectives identified were: 1. Increase understanding of disease prevention techniques to improve future health outcomes. 2. Increase the availability of nutrition education by implementing a trial Intuitive Eating program. 3. Increase the accessibility to fitness activities during the winter months. Educational and organizational diagnosis: The learning objectives were subdivided into cognitive, affective, and psychomotor skills as follows: 1. Cognitive - By the end of the program, 80% will identify the Intuitive Eating principles to assist in weight management and identify the society-driven messages that lead to low self-esteem. 2. Affective: a) Improve the percentage who feel they listen to their body signals (hunger and satiety) from 25% to 35%. b) Reduce the percentage who eat for nonbiological reasons from 80% to 60%. c) Improve the relationship with food by (1) decreasing the percentage who felt food was on their mind from 46% to 30%, and (2) decreasing the percentage of those feeling guilty about the food they ate from 36% to 25%. d) Improve the percentage who felt pleased with the way they managed what they ate from 18% to 25%. e) By the end of the program, 70% of the participants will (1) believe that weight management should be a slow process they can influence; (2) believe that dieting sets up a negative cycle of failure; (3) believe that healthful eating is important in raising a healthy family; (4) believe that physical activity is important to maintain a healthful lifestyle; and (5) believe that every individual has skills, abilities, and strengths that are more important than body size and shape and can be attractive. 3. Psychomotor skills: By the end of the program, 60% will be able to make healthful food choices and perform the physical activity needed to increase physical fitness. The resources objective identified was: By the end of the program, 100% of the participants will have access to a fitness facility, nutrition guidance, healthful food choices, and a social support group. PRECEDE indicates Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation; BMI, body mass index. a These objectives represent survey results and goals for change to assist with program design.
The mean BMI was 32 7, with 65% falling within the obese category. A BMI objective of no change was developed, since weight management is a slow process and 10 weeks may not be adequate to obtain a significant change.
Behavioral and Environmental Diagnosis Two thirds of participants had dieted in the past and one third were currently on or planning to start a new diet. Participants identified the importance of physical activity, but only one third met recommended guid-
ance, partially owing to child care issues and inclement weather. Mean HEI score of 66 9.2 was obtained, similar to the national average of 63.19 The mean Dieting Mentality scale score of 82 11.7 signified an overall dieting mind-set (87% of sample scoring between 80 to 127 points). Restrictive eating, emotional eating, guilt with food choices, and weight loss as being more important than overall well-being were identified as areas for concern. Results of the dieting mentality scale supported emphasis on certain topics within IE principles. Behavioral and environmental objectives identified are reported in Table 2.
Educational and Organizational Diagnosis Positive and negative predisposing (based on beliefs, attitudes, and behaviors), enabling, and reinforcing factors were identified. Many of the survey response trends focused on self-image/self-worth and emotional eating, contributing to a negative diet mentality cycle (ie, restrictive eating, elimination of specific nutrients, or guilt associated with food choices). Most of the respondents realized they have good qualities but are often overly self-critical and feel willpower is lacking. Stage of Change results shaped process of change techniques
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124 Cole and Horacek Table 3. 10-Week Intuitive Eating Sessions
Session 1: Hitting ‘‘diet bottom’’ and the ‘‘Intuitive Eating’’ overview Dieting facts and consequences, defined intuitive eating, and added a personal behavioral audit to assess factors contributing to their current dietary habits. Session 2: Rejecting the diet mentality Review of traditional diet vs nondieting approach to weight management,21 negative dieting cycle and elimination of dieting tools. Added SMART goal-setting method (specific, measurable, attainable, realistic, and time-based)22 to increase accountability throughout the program. Session 3: Honoring hunger and feeling fullness Merged principles and added education of digestive system, how hunger and fullness are triggered, how our blood sugar levels are maintained, calories in/out, and hunger/fullness discovery scale. Session 4: Challenge the food police Challenging society-driven concepts of parental/female roles, negative inner thoughts, and managing their inner voices regarding food, fitness, and self-worth. Session 5: Exercise—Feel the difference Benefits of activity, barriers to fitness, and determining alternative avenues.23-25 Addressed principle earlier with addition of a pedometer walking program and other tools.17 Session 6: Make peace with food and discover the satisfaction of food Merged the principles: All food items in moderation are acceptable, and food tastes/satisfaction change through the meal. Added activities on forbidden food items and a taste panel to evaluate sensory qualities. Session 7: Coping with emotions What is emotional eating, common triggers, and how to identify true emotions. Activity to identify if hunger is emotional, ways to cope and reshape self-thoughts. Session 8: Respecting your body and identifying your support group Accepting our qualities and reinforced changing negative self-talk. Concept of social support group25 and identifying and changing supporters and saboteurs. Session 9: Gentle nutrition Nutrition is important but will sabotage efforts if introduced too early. Covers 3 basic tenets: moderation, balance, and variety. Activities on reading food labels, identifying serving sizes (with food models), healthful dining out, and understanding nutrition claims. Session 10: Disease prevention and healthful meal Disease prevention information chosen by class and a healthful meal. SMART indicates specific, measurable, attainable, realistic, and time-based.
and tailored the intervention toward contemplation and preparation. Learning and resource objectives are reported in Table 2.
Administrative and Policy Diagnosis Several issues were identified in the administrative and policy diagnosis: health care, program funding, facility access, and use of a commercially available presentation. Military spouses tend to use civilian weight loss programs as a result of limited access to nutrition services at Fort Drum. As a result of limited child care services, an unsuccessful attempt was made to offer alternative child care options, indicating a level of complexity that should be explored further. Administrative resources were provided by the Fort Drum Medical Facility Command, and a small grant was obtained from
Syracuse University’s Nutrition and Hospitality Management Department to cover some program expenses. The Fort Drum Directorate of Community Activities provided access to the fitness facility trainers and resources for facility orientation and assist with anthropometric measurements. The commercially available presentation outlining the Tribole and Resch book was purchased to enhance program development, however a new presentation template was developed based on P-P model results.
Program Development Key highlights of the program structure that were altered or added as a result of the participatory planning process are listed as follows: Developed a program name and logo, ‘‘My Body Knows When.’’
Ten weekly sessions, 3 classes per week with 12-15 participants. A planned ‘‘Kick-Off’’ event to serve as an icebreaker and provide randomization results. Program incentives: biweekly prize drawings, a healthful meal, program t-shirts/fitness bags, and gift cards. Addition of weekly open discussion, activities, homework, and a participant program binder with a self-discovery journal. Several ‘‘A New You: Health for Every Body’’ IE educational materials from WIN the Rockies were incorporated.17 Levity was added through 25 dietand health-related cartoons from Randy Glasbergen (http://www. glasbergen.com) to help depict specific learning points. The IE principles were reordered from the published methodology by Tribole and Resch3 with special emphasis based on the PRECEDE
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009 results and objectives to better target the Fort Drum military spouses (Table 3).
DISCUSSION Participatory planning was accomplished through the consolidated application of P-P via a participant survey and planning/steering committee focus groups conducted simultaneously. Participant survey results provided data required for the PRECEDE diagnostic phases that lay the foundation for program planning and tailoring.10-14,27 Participatory planning is particularly important when developing a program for military family members, since they often have additional stresses imposed on them that affect dietary and lifestyle habits compared to their civilian counterpart and may have difficulty meeting the Healthy People 2010 objectives.26,28 Planning committee input, which was crucial to program planning, formed the basis of the administrative and policy diagnosis. Medical facility management representatives were able to influence current policies and identify potential barriers as well as authorize funds and resources needed for successful program development. The steering committee was essential to the success of the program development, since they took ownership of the ‘‘My Body Knows When’’ program and were instrumental in making many decisions related to program times, length of sessions, incentives, and activities identified through the PRECEDE diagnostic steps. Braun et al highlighted how ownership is created when the program is given an identity through the use of a slogan and logo, careful calendar timing, and use of incentives.29 Assessment of the participants’ stage of change4 promoted the incorporation of proper education techniques and strategies targeting those in contemplation and preparation stages for change, such as (1) consciousness-raising information; (2) environmental re-evaluation; (3) increasing confidence in one’s ability to adopt recommended behaviors; and (4) resolution of ambivalence, adopting a firm commitment, and defining a specific action plan. If the
program was designed properly, one would expect participants to transition from a dieting mentality to an IE mentality. This study found that it was possible to use consolidated PRECEDE diagnostic phases and appeared to be an effective tool to provide adequate data required to set objectives and criteria needed for participatory program development. Limitations of the study include a 31% recruitment rate from the participants completing the survey packet and the lack of validated studies for IE surveys.
Cole and Horacek 125
5.
6.
7.
IMPLICATIONS FOR RESEARCH AND PRACTICE Program tailoring to meet the needs of participants reduces potential barriers for program compliance, including attendance, and increases the likelihood of successful outcomes, making the program more sustainable for the future. PRECEDE-PROCEED is a functional model for participatory program planning and can be successful when a version consolidated to alleviate time constraints is used. Using P-P to develop an IE program may assist in improving the overall health and welfare of military spouses and contribute to meeting the HP 2010 objectives, since IE is a holistic approach to long-term behavior change supporting healthful lifestyle habits. Further research is needed to validate the IE instruments used and to assess this study’s tailored program effectiveness.
REFERENCES 1. ADA. Position of the American Dietetic Association: Weight Management. J Am Diet Assoc. 2002;102: 1145-1155. 2. American Obesity Association. AOA Fact Sheet. Available at: http://obesity1. tempdomainname.com/subs/fastfacts/ Obesity_Consumer_Protect.shtml. Accessed February 8, 2008. 3. Tribole E, Resch E. Intuitive Eating, a Revolutionary Program That Works. New York: Saint Martin’s Paperbacks; 1995. 4. Prochaska J, Norcross J, Diclemente C. Changing for Good: A Revolutionary Six-
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stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Avon Books; 1994. Roux L, Ubach C, Donaldson C, Ryan M. Valuing the benefits of weight loss programs: an application of the discrete choice experiment. Obes Res. 2004;12:1342-1351. Savage C, Xu Y, Lee R, Rose B, Kappesser M, Anthony J. A case study in the use of community-based participatory research in public health nursing. Public Health Nurs. 2006;23: 472-278. Watson M. Barriers to achieving and maintaining the oral health of Hispanics: Working with the community to develop a community-based oral health promotion program. Compendium. 2002;23:33-35. Bhuyan K. Health promotion through self-care and community participation: elements of a proposed programme in the developing countries. BMC Pub Health. 2004;4:1-12. Naylor PJ, Wharf-Higgins J, Blair L, Green L, O’Connor B. Evaluating the participatory process in a communitybased heart health project. Soc Sci Med. 2002;55:1173-1187. Green L, Kreuter M. Health Promotion Planning: An Educational and Environmental Approach. 2nd ed. Mountain View, CA: Mayfield Publishing Company; 1991. Green LW, Kreuter MW. CDC’s Planned Approach to Community Health as an application of PRECEDE and an inspiration for PROCEED. J Health Educ. 1992;23:140-147. Keith SE, Doyle EI. Using PRECEDE/PROCEED to address diabetes within the Choctaw Nation of Oklahoma. Am J Health Behav. 1998;22: 358-367. Hale JF. Application of the PRECEDEPROCEED Model for comprehensive community assessment, education programming, and evaluation in a combat hospital community during the Gulf War. Home Health Care Management and Practice. 1998;11:52-65. Horacek T, Koszewski W, Young L, Miller K, Betts N, Schnepf M. Development of a peer nutrition education program applying PRECEDE/PROCEED: a program planning model. Top Clin Nutr. 2000;15:19-27. Cole R. Intuitive Eating Non-Dieting Approach to Weight Management: A Pilot Study with Fort Drum Health Beneficiaries. UMI#3251799. UMI Dissertation
126 Cole and Horacek Services, ProQuest Co.: Ann Arbor, Mich; 2006. 16. Barr JT, Schumacher GE. The need for a nutrition-related quality-of-life measure. J Am Diet Assoc. 2003;103:177-180. 17. Wellness In the Rockies (WIN the Rockies). A New You: Health for Every Body. Available at: http://www. uwyo.edu/WINTHEROCKIES_EDUR/ ANewYou.asp. Accessed January 7, 2009. The stages of change instrument is at: http://www.uwyo.edu/ WINTHEROCKIES_EDUR/A%20 New%20You/Handouts/Lesson%201% 20Handouts/15%20Readiness%20for% 20Change.pdf. The preprogram Intuitive Eating Attitudes and Behavior survey is at http://www.uwyo.edu/ WINTHEROCKIES_EDUR/A%20 New%20You/Handouts/Lesson%201%20 Handouts/Pre-program%20Questionnaire. pdf. 18. Hugs International Inc (Omichinski L). The Dieting Mentality Quiz from ‘‘You Count, Calories Don’t.’’ Available at: http://www.hugs.com/Forum_ Docs_Attachs/FNCE_handouts_2002. pdf. Accessed January 7, 2009.
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009 19. Kennedy ET, Ohls J, Carlson S, Fleming K. The healthy eating index: design and application. J Am Diet Assoc. 1995;95:1103-1108. 20. Fowler FJ. Improving Survey Questions. Design and Evaluation. Applied Social Research Methods Series. Vol. 38. Thousand Oaks, CA: SAGE Publications, Inc; 1995:78-137. 21. King N. Moving Away from Diets. Lake Dallas, TX: Helms Seminars Publishing; 1999:7. 22. CDC 2000. National Center for Chronic Disease Prevention and Health Promotion, Motivation: Defining your goals. Available at: http://www.cdc.gov/ nccdphp/dnpa/physical/growing_stronger/ motivation/define_goals.htm. Accessed January 7, 2009. 23. Penn State University Recreational Sports Fitness (PSU). Fitness myths. Available at: http://www.clubs.psu. edu/fitnessprograms/myths.htm. Accessed January 7, 2009. 24. Robbins G, Powers D, Burgess S. A Wellness Way of Life. 4th ed. Boston, MA: WCB McGraw-Hill; 1999: 60,269,271,428-429,430-433.
25. McGraw P. Ultimate Weight Solution: Seven Keys to Weight Loss Freedom. New York: Free Press Division of Simon & Schuster Inc.; 2003. 26. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000. 27. Ramey SL, Shelley MC, Welk GJ, Franke WD. Cardiovascular disease risk reduction efforts among law enforcement officers: an application of the PRECEDE-PROCEED planning model. Evidence-Based Prev Med. 2003;1:1-10. 28. Harrell MC, Lim N, Castaneda LW, Golinelli D. Working Around the Military: Challenges to Military Spouse Employment and Education. Pittsburgh, PA: RAND National Defense Research Institute, RAND Corp; 2004:xviii-xxviii,13-21. 29. Braun W, Horton W, Storlie J. Guidelines for Employee Health Promotion Programs. Association for Worksite Health Promotion. Champaign, IL: Human Kinetics; 1992.
INTRODUCTION The American Dietetic Association supports the concept of providing combined weight and lifestyle management interventions rather than focusing solely on weight loss alone.1 Weight management intervention goals should be to prevent weight gain, improve physical and emotional health, and move toward realistic weight loss goals achieved through sensible and tolerable eating and exer-
1
cise behaviors, while preventing use of unreasonable dieting techniques, tools, and behaviors that lead to a dieting mentality.1 It is estimated that 45 million Americans diet each year and spend $30 billion per year on their dieting efforts.2 Intuitive eating (IE) epitomizes the nondieting approach to weight management by reinforcing behavior change without focusing specifically on weight loss.3 Intuitive eating modifies current habits to incorporate
Outpatient Nutrition Clinic, Brooke Army Medical Center, Fort Sam Houston, TX (completed study as a doctoral student at Syracuse University, Syracuse, NY) 2 Dietetics Department of Nutrition and Hospitality Management, Syracuse University, Syracuse, NY This research was conducted at the Fort Drum Medical and Dental Activity Center, Fort Drum, New York, and the Department of Nutrition and Hospitality Management, College of Human Development, Syracuse University, Syracuse, New York. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the United States government. Address for correspondence: Renee E. Cole, Brooke Army Medical Center, 3851 Roger Brooke Dr, Fort Sam Houston, Texas 78234; Phone: (210) 916-3656; Fax: (210) 916-1991; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2008.03.006
120
healthful behaviors that support weight loss over time. To implement a successful IE program, tailoring the program to the population’s current readiness to make healthful behavior changes is important.4 Behavior change programs are often developed without adequate target population assessment. Participatory program planning allows for program tailoring by involving the target population in the design process to meet their needs and reduce their barriers for change.5-9 A model developed by Green and Kreuter,10 known as Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PRECEDEPROCEED) (P-P), is a health promotion planning model involving a detailed series of 9 steps or phases for the planning, implementation, and evaluation processes. Five PRECEDE phases identify priorities and objectives for a particular population. PROCEED phases provide criteria for policy, implementation, and
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009 evaluation. Typically each PRECEDE phase is performed individually and completed in sequence. The process can be time consuming, and adequate planning time is not always available to conduct the phases sequentially as originally intended. The purpose of this project was to use a consolidated version of the P-P model11-14 to design an IE program for Fort Drum military spouses in which intervention techniques focus on readiness to reject dieting mentality and make healthful lifestyle modifications. The results of the PROCEED evaluation of program effectiveness will be published separately.
METHODS Subjects Ninety-one military adult family members of the Fort Drum Army installation in Watertown, NY, aged 2065 years, volunteered for the study. Ninety-eight percent were married females with an average of 2 children. About 39% had a high school diploma or general educational diploma, 27% completed 2 years of college, and 34% had 4 years or more of college, and the annual average family income was between $25 000 and $50 000. The recruitment and consenting process was approved by the Syracuse University and Walter Reed Army Medical Center Institutional Review Boards.
Recruitment and Data Collection Procedure The program study was advertised over a 1.5-month time period through various Fort Drum media avenues. The advertisement asked for volunteers who were tired of dieting and would like to enjoy food without feeling guilty. Participants completed a survey packet with specific instructions, a consent form, received a small incentive for participating, and were given the opportunity to voluntarily participate in the intervention phase (the nondieting approach to weight management program).15
Model Design The P-P model was consolidated to diagnose the target population within
a shorter time period (outlined in Table 1).10 Demographic, epidemiological, behavioral, and organizational data were collected through the use of a single survey packet, not as distinct individual phases. Environmental, administrative and policy data were collected through focus groups composed of planning and steering committee members to capture additional PRECEDE diagnostic data, such as resources and funding availability, child care desires/options, and health care access/concerns. The planning committee, composed of medical facility management representatives, assisted in advertising and resource management and provided a network to overcome specific policy or administrative hurdles and improve program development. The steering committee, composed of volunteers from the target sample, met weekly prior to program start date and biweekly thereafter to provide their input on administrative hurdles faced.
Cole and Horacek 121 from BMI categories; BMI 18.5-24.9 depicts normal weight, BMI 25-29.9 depicts overweight, and BMI 30 and above depict obesity.1,26
Behavioral and educational measures. The Diet Mentality Scale score
The diagnostic data for each of the PRECEDE phases as listed in Table 1 were collected through the use of 5 surveys combined as 1 packet with the consent form and distributed at one time. The mean and mode of the survey questions provided the PRECEDE phase data to identify the most problematic areas requiring more attention to assist in development of the phase objectives and details for how to structure the program.
and Healthy Eating Index (HEI) score19 were selected to assess overall change in eating behaviors/attitudes to evaluate program effectiveness. The Diet Mentality Scale score was created for this study based on 33 survey questions16-18 (19 three-point and 14 five-point response questions) from the surveys noted in Table 1. Thus, 33 was the minimum and 127 was the maximum score. A score of 33 to 79 signified an intuitive eater and 80 to 127 as a dieter mentality. Questions focus on impact of food choices, self-image, self-efficacy, dieting habits, and physical activity habits. The mode and percentage of survey results will assist in program tailoring based on areas for IE improvement. A 3-day food record was completed, providing data to compute an overall HEI score. The HEI is based on a maximum of 100 points, with up to 10 points from each of 10 components: servings of grains, vegetables, fruits, milk, and meat, as well as total calories from fat, saturated fat from total fat calories, cholesterol, sodium, and food variety. For example, if 6 servings of grains are recommended and consumed, then 10 points were awarded. If 3 servings were consumed, then 5 points were awarded. If 0 servings were consumed, then 0 points were awarded.
Social measures focused on quality of life issues. An extensive list of life pri-
Educational and organizational measures. Unlike smoking, IE cannot
orities, stressors, and activity options, developed through pilot-testing, were provided with options for open comments in the Nutrition-Related Quality of Life Survey.
be defined by one distinct behavior, but it is a compilation of attitudes/behaviors relating to eating a variety of food, listening to hunger/fullness cues, and avoiding emotional eating. The Stages of Change for Pleasurable and Healthy Eating Habits Survey was used to determine participant Stage of Change (pre-contemplators, contemplators, preparers, taking action, in maintenance, or in the termination phase).17
Instruments, Data Processing, and Analysis
Epidemiological measures. Past and current medical conditions, body mass index (BMI, kg/m2), and weight were obtained at baseline data collection prior to complete analysis of survey data. Weight and height were measured with a validated electronic scale and stadiometer, respectively. Weight descriptions were determined
Organizational and administrative program mix. Various topics in
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122 Cole and Horacek
Table 1. PRECEDE-PROCEED Model Diagnostic Phases10 Diagnostic Phase Social
Epidemiological
Behavioral and environmental
Educational and organizational
Administrative and policy
PROCEED phases
Description Quality of life concerns and aspirations (social, economic, cultural, and environmental); top stressors, priorities, and activities enjoyed, support/pressure from family/friends, etc. Specific health goals and problems associated with quality of life issues identified; BMI, co-morbidities, other health conditions, etc. Specific health-related factors possibly linked to health problems identified. Target leisure activities (amount or frequency of physical activity, etc.), dietary habits (restrictive eating, emotional eating, past diets, diet tools, etc.), and attitudes toward weight loss and intuitive eating (importance of weight, weight management, self worth, etc.) Identify, sort, and categorize the predisposing, reinforcing, and enabling factors that influence health behaviors identified; dieting thoughts, following hunger/fullness cues, feelings about food choices, value of physical activity, ability to make healthful choices Budgetary and staff requirements and availability, barriers/limitations to overcome, and available policies to change or support Implementation, Evaluations – Process, Impact, Outcome
Assessment Method Open-ended questions plus Nutrition-Related Quality of Life Survey16
Retrospective History Survey and Anthropometric Measurements
Intuitive Eating Attitudes and Behaviors Survey,17 Dieting Mentality Quiz,18 Healthy Eating Index,19 3-day food records
Stages of Change for Pleasurable and Healthy Eating Habits Survey17
Focus group, Desired Program Mix Survey
Reported separately
PRECEDE-PROCEED indicates Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development; BMI, body mass index.
disease prevention, nutrition and weight management, physical activity, and program structure desired were included in the survey. Program mix options included preferred day and time for class, number and length of sessions, type of learning environment, incentives, and the desire for babysitting, educational pamphlets, and a class bulletin board. The specific PROCEED methods and results for the implementation and evaluation phases are reported elsewhere.15 The survey packet was pilot-tested by 20 noneligible representative spouses. The survey responses were tabulated to glean the following information: for appropriate responses, need for clarification, questions not
answered and why, and redundancy or inconsistencies.20 A revised survey packet was approved by the Syracuse University Nutrition Department and the Institution Review Boards from Syracuse University and Walter Reed Army Medical Center.
Social Diagnosis Priorities in life tended to center around family health, happiness, and financial stability. The top 2 stressors related to participants’ body image and ability to control weight. Identified objectives are reported in Table 2.
RESULTS Of 295 surveys distributed, 91 were returned and analyzed (31% response rate). Survey and focus group data collected for each phase of the PRECEDE diagnosis were used by investigators to develop the objectives, assist with program design and plan process, impact, and outcome evaluations.
Epidemiological Diagnosis Thirty percent of the health concerns revolved around common health indicators: high blood pressure, high blood cholesterol, and diabetes. Disease prevention education material was incorporated into the program.
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Table 2. PRECEDE Phase Objectives Identifieda Social diagnosis: 1. Improve self-image such that ‘‘current weight status’’ is no longer ranked within the top 5 life stressors. 2. Reduce the percentage of those who would feel happier if they lost weight from 90% to 80%. 3. Reduce the percentage of those who are unhappy with the way they look from 90% to 80%. 4. Improve ability to engage in physical activity such that ‘‘lack of physical activity’’ is no longer ranked in the top 5 life stressors. Epidemiological diagnosis: No BMI change is expected because of short program duration. Behavioral and environmental diagnosis: The behavioral objectives identified were: 1. Increase physical activity from 39% to 50% being active 30 minutes 3 times per week. 2. Increase the percentage abandoning restrictive diets from 13% to 25% through education. 3. Shift the mean Healthy Eating Index score from 65 to 72 by the end of the program. 4. Shift the mean Diet Mentality score from 82 to 74 by the end of the program. The environmental objectives identified were: 1. Increase understanding of disease prevention techniques to improve future health outcomes. 2. Increase the availability of nutrition education by implementing a trial Intuitive Eating program. 3. Increase the accessibility to fitness activities during the winter months. Educational and organizational diagnosis: The learning objectives were subdivided into cognitive, affective, and psychomotor skills as follows: 1. Cognitive - By the end of the program, 80% will identify the Intuitive Eating principles to assist in weight management and identify the society-driven messages that lead to low self-esteem. 2. Affective: a) Improve the percentage who feel they listen to their body signals (hunger and satiety) from 25% to 35%. b) Reduce the percentage who eat for nonbiological reasons from 80% to 60%. c) Improve the relationship with food by (1) decreasing the percentage who felt food was on their mind from 46% to 30%, and (2) decreasing the percentage of those feeling guilty about the food they ate from 36% to 25%. d) Improve the percentage who felt pleased with the way they managed what they ate from 18% to 25%. e) By the end of the program, 70% of the participants will (1) believe that weight management should be a slow process they can influence; (2) believe that dieting sets up a negative cycle of failure; (3) believe that healthful eating is important in raising a healthy family; (4) believe that physical activity is important to maintain a healthful lifestyle; and (5) believe that every individual has skills, abilities, and strengths that are more important than body size and shape and can be attractive. 3. Psychomotor skills: By the end of the program, 60% will be able to make healthful food choices and perform the physical activity needed to increase physical fitness. The resources objective identified was: By the end of the program, 100% of the participants will have access to a fitness facility, nutrition guidance, healthful food choices, and a social support group. PRECEDE indicates Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation; BMI, body mass index. a These objectives represent survey results and goals for change to assist with program design.
The mean BMI was 32 7, with 65% falling within the obese category. A BMI objective of no change was developed, since weight management is a slow process and 10 weeks may not be adequate to obtain a significant change.
Behavioral and Environmental Diagnosis Two thirds of participants had dieted in the past and one third were currently on or planning to start a new diet. Participants identified the importance of physical activity, but only one third met recommended guid-
ance, partially owing to child care issues and inclement weather. Mean HEI score of 66 9.2 was obtained, similar to the national average of 63.19 The mean Dieting Mentality scale score of 82 11.7 signified an overall dieting mind-set (87% of sample scoring between 80 to 127 points). Restrictive eating, emotional eating, guilt with food choices, and weight loss as being more important than overall well-being were identified as areas for concern. Results of the dieting mentality scale supported emphasis on certain topics within IE principles. Behavioral and environmental objectives identified are reported in Table 2.
Educational and Organizational Diagnosis Positive and negative predisposing (based on beliefs, attitudes, and behaviors), enabling, and reinforcing factors were identified. Many of the survey response trends focused on self-image/self-worth and emotional eating, contributing to a negative diet mentality cycle (ie, restrictive eating, elimination of specific nutrients, or guilt associated with food choices). Most of the respondents realized they have good qualities but are often overly self-critical and feel willpower is lacking. Stage of Change results shaped process of change techniques
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124 Cole and Horacek Table 3. 10-Week Intuitive Eating Sessions
Session 1: Hitting ‘‘diet bottom’’ and the ‘‘Intuitive Eating’’ overview Dieting facts and consequences, defined intuitive eating, and added a personal behavioral audit to assess factors contributing to their current dietary habits. Session 2: Rejecting the diet mentality Review of traditional diet vs nondieting approach to weight management,21 negative dieting cycle and elimination of dieting tools. Added SMART goal-setting method (specific, measurable, attainable, realistic, and time-based)22 to increase accountability throughout the program. Session 3: Honoring hunger and feeling fullness Merged principles and added education of digestive system, how hunger and fullness are triggered, how our blood sugar levels are maintained, calories in/out, and hunger/fullness discovery scale. Session 4: Challenge the food police Challenging society-driven concepts of parental/female roles, negative inner thoughts, and managing their inner voices regarding food, fitness, and self-worth. Session 5: Exercise—Feel the difference Benefits of activity, barriers to fitness, and determining alternative avenues.23-25 Addressed principle earlier with addition of a pedometer walking program and other tools.17 Session 6: Make peace with food and discover the satisfaction of food Merged the principles: All food items in moderation are acceptable, and food tastes/satisfaction change through the meal. Added activities on forbidden food items and a taste panel to evaluate sensory qualities. Session 7: Coping with emotions What is emotional eating, common triggers, and how to identify true emotions. Activity to identify if hunger is emotional, ways to cope and reshape self-thoughts. Session 8: Respecting your body and identifying your support group Accepting our qualities and reinforced changing negative self-talk. Concept of social support group25 and identifying and changing supporters and saboteurs. Session 9: Gentle nutrition Nutrition is important but will sabotage efforts if introduced too early. Covers 3 basic tenets: moderation, balance, and variety. Activities on reading food labels, identifying serving sizes (with food models), healthful dining out, and understanding nutrition claims. Session 10: Disease prevention and healthful meal Disease prevention information chosen by class and a healthful meal. SMART indicates specific, measurable, attainable, realistic, and time-based.
and tailored the intervention toward contemplation and preparation. Learning and resource objectives are reported in Table 2.
Administrative and Policy Diagnosis Several issues were identified in the administrative and policy diagnosis: health care, program funding, facility access, and use of a commercially available presentation. Military spouses tend to use civilian weight loss programs as a result of limited access to nutrition services at Fort Drum. As a result of limited child care services, an unsuccessful attempt was made to offer alternative child care options, indicating a level of complexity that should be explored further. Administrative resources were provided by the Fort Drum Medical Facility Command, and a small grant was obtained from
Syracuse University’s Nutrition and Hospitality Management Department to cover some program expenses. The Fort Drum Directorate of Community Activities provided access to the fitness facility trainers and resources for facility orientation and assist with anthropometric measurements. The commercially available presentation outlining the Tribole and Resch book was purchased to enhance program development, however a new presentation template was developed based on P-P model results.
Program Development Key highlights of the program structure that were altered or added as a result of the participatory planning process are listed as follows: Developed a program name and logo, ‘‘My Body Knows When.’’
Ten weekly sessions, 3 classes per week with 12-15 participants. A planned ‘‘Kick-Off’’ event to serve as an icebreaker and provide randomization results. Program incentives: biweekly prize drawings, a healthful meal, program t-shirts/fitness bags, and gift cards. Addition of weekly open discussion, activities, homework, and a participant program binder with a self-discovery journal. Several ‘‘A New You: Health for Every Body’’ IE educational materials from WIN the Rockies were incorporated.17 Levity was added through 25 dietand health-related cartoons from Randy Glasbergen (http://www. glasbergen.com) to help depict specific learning points. The IE principles were reordered from the published methodology by Tribole and Resch3 with special emphasis based on the PRECEDE
Journal of Nutrition Education and Behavior Volume 41, Number 2, 2009 results and objectives to better target the Fort Drum military spouses (Table 3).
DISCUSSION Participatory planning was accomplished through the consolidated application of P-P via a participant survey and planning/steering committee focus groups conducted simultaneously. Participant survey results provided data required for the PRECEDE diagnostic phases that lay the foundation for program planning and tailoring.10-14,27 Participatory planning is particularly important when developing a program for military family members, since they often have additional stresses imposed on them that affect dietary and lifestyle habits compared to their civilian counterpart and may have difficulty meeting the Healthy People 2010 objectives.26,28 Planning committee input, which was crucial to program planning, formed the basis of the administrative and policy diagnosis. Medical facility management representatives were able to influence current policies and identify potential barriers as well as authorize funds and resources needed for successful program development. The steering committee was essential to the success of the program development, since they took ownership of the ‘‘My Body Knows When’’ program and were instrumental in making many decisions related to program times, length of sessions, incentives, and activities identified through the PRECEDE diagnostic steps. Braun et al highlighted how ownership is created when the program is given an identity through the use of a slogan and logo, careful calendar timing, and use of incentives.29 Assessment of the participants’ stage of change4 promoted the incorporation of proper education techniques and strategies targeting those in contemplation and preparation stages for change, such as (1) consciousness-raising information; (2) environmental re-evaluation; (3) increasing confidence in one’s ability to adopt recommended behaviors; and (4) resolution of ambivalence, adopting a firm commitment, and defining a specific action plan. If the
program was designed properly, one would expect participants to transition from a dieting mentality to an IE mentality. This study found that it was possible to use consolidated PRECEDE diagnostic phases and appeared to be an effective tool to provide adequate data required to set objectives and criteria needed for participatory program development. Limitations of the study include a 31% recruitment rate from the participants completing the survey packet and the lack of validated studies for IE surveys.
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5.
6.
7.
IMPLICATIONS FOR RESEARCH AND PRACTICE Program tailoring to meet the needs of participants reduces potential barriers for program compliance, including attendance, and increases the likelihood of successful outcomes, making the program more sustainable for the future. PRECEDE-PROCEED is a functional model for participatory program planning and can be successful when a version consolidated to alleviate time constraints is used. Using P-P to develop an IE program may assist in improving the overall health and welfare of military spouses and contribute to meeting the HP 2010 objectives, since IE is a holistic approach to long-term behavior change supporting healthful lifestyle habits. Further research is needed to validate the IE instruments used and to assess this study’s tailored program effectiveness.
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25. McGraw P. Ultimate Weight Solution: Seven Keys to Weight Loss Freedom. New York: Free Press Division of Simon & Schuster Inc.; 2003. 26. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000. 27. Ramey SL, Shelley MC, Welk GJ, Franke WD. Cardiovascular disease risk reduction efforts among law enforcement officers: an application of the PRECEDE-PROCEED planning model. Evidence-Based Prev Med. 2003;1:1-10. 28. Harrell MC, Lim N, Castaneda LW, Golinelli D. Working Around the Military: Challenges to Military Spouse Employment and Education. Pittsburgh, PA: RAND National Defense Research Institute, RAND Corp; 2004:xviii-xxviii,13-21. 29. Braun W, Horton W, Storlie J. Guidelines for Employee Health Promotion Programs. Association for Worksite Health Promotion. Champaign, IL: Human Kinetics; 1992.