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Exercise as a Gateway Behavior for Healthful Eating among Older Adults: An Exploratory Study
RESEARCH BRIEF
Exercise as a Gateway Behavior for Healthful Eating among Older Adults: An Exploratory Study M I C H E L L E T U C K E R , MS; M A R L A R E I C K S , P H D, RD Department of Food Science and Nutrition, University of Minnesota, St. Paul, Minnesota 55108
INTRODUCTION
ABSTRACT
Nutrition and physical activity contribute to the health, selfsufficiency, and quality of life for older adults. Nutrition education interventions may be more effective in promoting positive and productive aging if attention is paid to the manner in which health behaviors are related. It has been suggested that there are potential gateway behaviors to health for older adults.1 A gateway behavior is a health behavior that, when positively changed, would cause a positive change in another health behavior. As gateway behaviors to health are identified for older adults, interventions could focus on only one or two key behaviors, and changes in other behaviors would ensue. Preliminary study using the Transtheoretical Model (TTM) has shown that the interrelationships between various health behaviors increase with age.1 The TTM has been successfully applied to older adults relative to smoking cessation,2 exercise,3 and multiple eating behaviors including avoiding fat, eating fiber, and losing weight.1 The TTM explains intentional exercise and eating behavior change based on movement through a series of stages.4 The stages include the precontemplation stage (the individual is not doing or intending to do the target behavior in the next 6 months), the contemplation stage (the individual intends to change but not soon), the preparation stage (the individual intends to change in the next month), the action stage (the individual actively engages in the new behavior for less than 6 months), and the maintenance stage (the individual has maintained the change in the target behavior for at least 6 months). In the earlier stages, the importance of the benefits and barriers to making behavior changes is considered. In the later stages, self-efficacy functions to help the individual make and maintain changes.Various processes of change are used by individuals as they progress through the stages focusing on thoughts, feelings, experiences, behaviors, and reinforcement. A recent surgeon general’s report5 advocates increasing levels of physical activity for older adults given the evidence for reduction of the risk of certain chronic diseases, maintenance of independent living, and enhancement of overall quality of life. National Health Interview Survey results have recently shown that the percentage of older persons who were sedentary declined between 1985 and 1995, from 34%
Context: The relationship between eating and exercise behavior change may influence effectiveness of interventions for older adults. Objective: To determine whether exercise is a potential gateway behavior for healthful eating behavior among older adults. Design: The Transtheoretical Model was applied to eating and exercise behaviors through the administration of a crosssectional survey. Setting/Participants: 205 older adults (the majority were white women) participating in congregate dining programs in a large Midwestern city. Variables Measured: Perceived benefits and barriers, self-efficacy, and stage of change related to exercise and eating habits Analysis: Differences in responses to survey items based on stage of change were determined by analysis of variance, P < .05. Results: Subjects in later stages for exercise behavior were also likely to be in later stages for eating adequate servings of fruit and dairy products but not for vegetables and avoiding fat. Conclusions and Implications: Exercise is a potential gateway behavior for some dietary behaviors for older adults, justifying further controlled, longitudinal research. KEY WORDS: way behavior
older adults,Transtheoretical Model, gate( J Nutr Educ Behav. 2002;S14-S19.)
This research has been supported in part by the Minnesota Agricultural Experiment Station. Address for correspondence: Marla Reicks, PhD, RD, Department of Food Science and Nutrition, University of Minnesota, 162 FScN, 1334 Eckles Avenue, St. Paul, MN 55108;Tel: (612) 624-4735; Fax: (612) 625-5272; E-mail: [email protected]. ©2002 SOCIETY FOR NUTRITION EDUCATION
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Journal of Nutrition Education and Behavior Volume 34 Supplement 1
to 28% among men and from 44% to 39% among women.6 Exercise behavior may be an ideal gateway behavior to changing eating behaviors as older adults realize benefits from being more physically active and desire to intensify these benefits by improving other health behaviors. The purpose of the current study was to apply the TTM to the exercise and eating habits of older adults in a preliminary manner in preparation for further longitudinal study. The hypotheses that were tested were (1) there are positive relationships between stage of exercise and healthful eating behaviors (eating adequate amounts of fruits, vegetables, and dairy products and avoiding fat), indicating that exercise is a potential gateway behavior for diet-related behaviors, and (2) there are positive relationships between stages of change, self-efficacy, and decisional balance (benefits and barriers) for exercise and healthful eating behaviors.
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Stage of exercise behavior response options was related to the question, “Do you exercise regularly according to the definition (regular exercise is any planned physical activity [eg, walking, low-impact aerobics, bicycling, swimming, etc] performed to increase physical fitness)?” Stage of eating behavior response options was related to the question, “Do you eat x number of servings of x food type on a typical day?” Possible response options were “Yes, I have been for more than 6 months” (maintenance), “Yes, I have been for less than 6 months” (action),“No, but I intend to in the next 30 days” (preparation), “No, but I intend to in the next 6 months” (contemplation), or “No, and I do not intend to in the next 6 months” (precontemplation). Because the stage distribution was bipolar, the precontemplation, contemplation, and preparation stages were combined into a pre-action stage, whereas the action and maintenance stages were combined into a post-action stage.
DESCRIPTION OF THE SURVEY DESCRIPTION OF THE SURVEY RESULTS A convenience sample of subjects (N = 205) was recruited from 11 dining sites for older adults managed by a volunteer association within a large Midwestern city and its surrounding suburbs. Dining sites were selected based on representation from inner city and suburban sites but did not include sites that catered specifically to immigrant populations or to less independent older adults living in high-rise buildings. The subjects were asked to provide consent to participate according to the Institutional Review Board Human Subjects Protection Committee prior to completing a self-administered survey either before or after a noon meal. The survey took approximately 20 minutes to complete, and a travel mug or stress ball was offered as a token of appreciation. Less than 10% of those participating in the meal at the selected dining sites refused to complete the survey. The survey was read to those who requested assistance. Survey items were developed based on the research questions and were adapted from other studies when appropriate. The items were related to demographic information, food security,7 self-reported exercise,8,9 stages of change,1 self-efficacy,10 and benefits and barriers related to exercise and healthy eating.11-13 The survey was pretested with older adults at a senior health fair in the same city to estimate the reliability of survey items and for clarity. Based on the results of the pilot test, questions were modified as needed. Cronbach coefficient was .58 for stage of eating behaviors, .84 for the perceived benefits to exercise, .76 for the perceived barriers to exercise, .72 for the perceived benefits to eating healthful meals, and .63 for the perceived barriers to eating healthful meals. Statistical analyses were performed using SAS software (Statistical Analysis Systems,Version 6.12, Cary, NC). Analysis of variance (ANOVA) was used to determine differences in responses to survey items based on stage of dietary behavior or stage of exercise. A significance level of P < .05 was considered significant.
Demographic data are summarized in Table 1. The sample consisted of 205 mostly white adults 65 years of age and older, with the majority of the population being female. Table 1.
Characteristics of Subjects* %
n
65-70
17.2
35
71-75
20.2
41
76-80
29.1
59
81-85
21.2
43
86-91+
12.3
25
Age, yr
Gender Male
31.5
64
Female
68.5
139
93.2
191
6.8
14
Ethnicity White African American Marital status Married Never married
29.7
60
5.4
11
Widowed
49.0
99
Divorced
15.8
32
Education level High school or less
47.0
95
Some or completed technical/vocational school
22.8
46
Some or completed college
22.3
45
7.0
16
Postgraduate Does current financial situation limit amount of money that can be spent on food? Yes
16.0
32
No
84.0
168
*N ranged from 200 to 205 among questions.
S16 Table 2.
Tucker and Reicks/EXERCISE AS A GATEWAY BEHAVIOR FOR HEALTHFUL EATING AMONG OLDER ADULTS Frequency Distribution across the Stages for Exercise and Consumption of Fruit, Vegetables, and Dairy Products and Avoiding Fat*
Stage
Precontemplation
Contemplation
Preparation
Action
Maintenance
Exercise
16.3 (33)
10.8 (22)
9.4 (19)
8.4 (17)
55.2 (112)
Avoiding fat
19.7 (40)
1.5 (3)
3.0 (6)
8.4 (17)
67.5 (137)
9.8 (20)
2.9 (6)
2.5 (5)
4.9 (10)
79.9 (163)
Vegetables (3+ servings/d)
16.7 (34)
3.9 (8)
9.9 (20)
2.5 (5)
67.0 (136)
Dairy products (3+ servings/d)
19.2 (39)
4.9 (10)
3.9 (8)
2.5 (5)
69.5 (141)
Fruit (2+ servings/d)
*Values represent percent of total N. The numbers in parentheses represent the n for each stage for each behavior.
Most of the population was either married or widowed. Almost half reported an education level of high school or less, whereas about one quarter had attended technical or vocational school or college. The majority did not indicate that they were financially limited in the amount of money they could spend on food. The distributions across the stages of change for exercise and healthy eating behaviors are presented in Table 2. Most of the subjects fell on the extreme ends for stages of health behavior change.The distribution of the participants in the stages of change for exercise shows that about half considered themTable 3.
selves to be in the maintenance stage and 16.3% considered themselves to be in the precontemplation stage. Nigg et al1 also found a similar bipolar distribution in stage of change for exercise for older adults compared with younger subjects, who were more evenly distributed across the stages.The polarity of the distribution in the stages of change for exercise would indicate that some have been exercising regularly for a long period of time, whereas others have not even considered exercising.The results in Table 2 show that many respondents also considered themselves to be in either the precontemplation or maintenance stages for healthful eating behaviors. Similar stage
Benefits and Barriers and Self-efficacy for Exercise and Reported Exercise by Stage*,†,‡ Stage of Exercise Pre-action
Post-action
Regular exercise is good for overall health.
3.89 ± 0.83
4.30 ± 0.81§
Exercise can improve strength and balance.
3.66 ± 0.99
4.22 ± 0.80§
Regular exercise would help have a more positive outlook on life.
3.41 ± 1.02
4.10 ± 0.92§
Easier to perform routine physical tasks if exercised regularly.
3.21 ± 1.03
3.80 ± 1.06§
Have more energy for friends/family if exercised regularly.
3.10 ± 0.99
3.68 ± 1.08§
Exercise is a good way to socialize with friends.
3.10 ± 1.06
3.48 ± 1.26§
Sleep more soundly if exercised regularly.
3.07 ± 1.09
3.43 ± 1.28§
Have physical limitations that make it difficult to exercise.
3.18 ± 1.47
2.40 ± 1.36§
Too much pain when exercising.
2.86 ± 1.25
2.06 ± 1.08§
Worry might fall or get hurt while exercising.
2.71 ± 1.31
1.98 ± 1.09§
Do not have time for regular exercise.
2.30 ± 1.01
1.84 ± 1.05§
Do not have any place to exercise.
2.07 ± 1.07
1.74 ± 0.97§
Too old to exercise regularly.
2.31 ± 1.28
1.74 ± 1.04§
Weight makes it difficult to exercise.
2.20 ± 1.04
1.72 ± 0.90§
2.14 ± 0.96
3.76 ± 0.93§
40.43 ± 98.03
173.84 ± 135.37§
108.04 ± 266.09
160.93 ± 343.81
Benefits/barriers to regular exercise
Self-efficacy Confident can exercise regularly Self-reported activity Time spent on planned physical activity, min Time spent on housework, min Time spent on volunteer activity, min Time spent on vigorous physical activity, min
79.46 ± 227.75
99.65 ± 189.82
3.45 ± 16.28
26.28 ± 73.86§
*N ranged from 68 to 74 for pre-action and 124 to 129 for post-action. † Benefits/barriers statement response options were on a scale of 1 to 5, where 1 = strongly disagree and 5 = strongly agree; self-efficacy was measured on a scale of 1 to 5, where 1 = not at all confident and 5 = completely confident. ‡ Values represent means ± SD. Section marks by post-action values indicate statistical significance compared to pre-action values at P < .05 according to ANOVA.
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that self-efficacy scores for exercise and perceived benefits and barriers to exercise were related to progress from precontemplation to maintenance stages for subjects with a mean age of 42 years. Confidence in one’s ability to maintain a regular exercise program was also found to be important for adherence to exercise programs for older adults.16,17 Table 3 shows the results related to the subjects’ self-reported amount of time spent on various types of activity. Those in the post-action stages were more likely to report greater time spent on planned or vigorous physical activity than those in the preaction stages. In general, most respondents agreed with the benefit statements and disagreed with the barrier statements for healthful eating behaviors (Table 4). Differences between perceptions of benefits and barriers by those in post- versus pre-action stages occurred for the stages of change for fruit and vegetable behavior more often than for the stages of change for dairy products or avoiding fat behaviors. For all eating behaviors, those in the post-action stages agreed more often with the benefit statement “I would feel better if I ate healthy meals” and disagreed more often with the barrier statement “Healthy meals cost too much to prepare” compared with those in the pre-action stages. Similar to the results related to exercise behavior, those in the post-action
distribution results were found for older adults by Nigg et al1 for low-fat and high-fiber changes and by Auld et al13 for lowfat eating behaviors.The perceptions of benefits and barriers to exercise in the current study are presented in Table 3 according to pre- or post-action stage of exercise.The results indicate that the most commonly held benefits of exercise were that it is good for overall health and improves strength and balance. Exercise as a way to socialize with friends or as a way to improve sleep was a less positively held benefit. The more commonly held barrier to exercise was having physical limitations or pain that makes it difficult to exercise, whereas the least commonly held barrier was being too old to exercise or that weight makes it difficult to exercise. Rhodes et al14 reviewed studies examining factors associated with exercise among older adults and found that the greatest perceived barriers were physical frailty and poor health. In the current study, agreement with each of the benefit statements was stronger for those individuals in the post-action compared with the preaction stages, whereas agreement with each of the barrier statements was weaker.There was also a significant difference in the level of self-confidence in the ability to exercise regularly between those classified in pre- versus post-action stage of exercise.This supports results in another study with a demographically different population group. Herrick et al15 found
Table 4.
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Benefits and Barriers and Self-efficacy for Healthful Eating and Diet-Related Items by Stage*,†,‡ Fruit Preaction
Vegetables Postaction
Preaction
Dairy
Postaction
Preaction
Avoiding Fat Postaction
Preaction
Postaction
Benefits/barriers to healthy meals Feel better
3.87 ± 0.67
4.21 ± 0.70§ 3.98 ± 0.59
4.24 ± 0.74§ 4.02 ± 0.77
4.21 ± 0.67§ 3.96 ± 0.91
4.23 ± 0.61§
More energy
3.68 ± 0.91
3.95 ± 0.94
3.80 ± 0.77
3.95 ± 1.00
3.95 ± 0.67
3.88 ± 1.02
3.71 ± 1.02
3.97 ± 0.90
Improves mental ability
3.03 ± 1.20
3.81 ± 0.99§ 3.61 ± 0.95
3.73 ± 1.11
3.77 ± 0.93
3.66 ± 1.11
3.49 ± 1.10
3.76 ± 1.04
Would not make a difference at my age
2.65 ± 1.11
2.54 ± 1.36
2.44 ± 1.35§ 2.53 ± 1.21
2.58 ± 1.36
2.94 ± 1.28
2.44 ± 1.31§
2.82 ± 1.22 2.77 ± 1.17
2.19 ± 1.13
§
Too much time to prepare
2.65 ± 1.08
2.32 ± 1.18
2.51 ± 1.05
2.32 ± 1.21
2.49 ± 1.17
2.33 ± 1.17
Do not taste very good
2.35 ± 1.20
1.80 ± 0.92§ 2.28 ± 1.14
1.72 ± 0.86§ 1.98 ± 0.95
1.86 ± 0.99
1.90 ± 0.80
1.88 ± 1.03
Cost too much to prepare
2.71 ± 1.13
1.98 ± 1.04§ 2.46 ± 1.06
1.93 ± 1.06§ 2.44 ± 1.07
1.97 ± 1.06§ 2.35 ± .99
2.01 ± 1.10§
On a diet recommended by a physician
1.67 ± 0.48
1.66 ± 0.49
1.75 ± 0.44
1.63 ± 0.50
1.64 ± 0.52
1.68 ± 0.47
1.93 ± 0.25
1.58 ± 0.51§
Financial situation limits the amount of money can spend on food
1.81 ± 0.40
1.84 ± 0.39
1.89 ± 0.32
1.81 ± 0.41
1.81 ± 0.40
1.84 ± 0.39
1.90 ± 0.31
1.81 ± 0.41
Number of meals eaten at home weekly
3.77 ± 1.31
3.94 ± 1.24
3.82 ± 1.42
3.94 ± 1.16
3.74 ± 1.28
3.97 ± 1.22
3.77 ± 1.26
3.97 ± 1.24
3.23 ± 0.97
3.84 ± 0.97§ 3.52 ± 1.04
3.83 ± 1.00§ 3.59 ± 1.13
3.81 ± 0.93
Diet-related items
Self-efficacy Confident can eat healthy meals regularly
3.86 ± 0.96§ 3.54 ± 0.97
*N ranged from 30 to 31 for pre-action and 167 to 173 for post-action for fruit, 60 to 62 for pre-action and 138 to 141 for vegetables, 55 to 57 for pre-action and 141 to 146 for post-action for dairy, and 46 to 49 for pre-action and 150 to 154 for post-action for cutting fat. † Benefits/barriers statement response options were on a scale of 1 to 5, where 1 = strongly disagree and 5 = strongly agree. For diet-related items, response options were on a diet recommended by a physician and financial situation limits money spent on food, 1 = yes, 2 = no; number of meals eaten at home weekly, < 1 = 1; 1-5 = 2; 6-10 = 3; 11-15 = 4; 16-20 = 5; > 20 = 6; and self-efficacy, 1 = not at all confident and 5 = completely confident. ‡ Values represent means ± SD. Section marks (§) by post-action values indicate statistical significance compared with pre-action values at P < .05 according to ANOVA.
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Tucker and Reicks/EXERCISE AS A GATEWAY BEHAVIOR FOR HEALTHFUL EATING AMONG OLDER ADULTS
stages for fruit, vegetable, and dairy product behaviors were more likely to report a higher level of confidence in their ability to eat healthful meals on a regular basis compared with those in the pre-action stages for these behaviors. Older persons may have problems consistently obtaining a nutritious diet given that about 1.6 to 2 million elderly households reported in 1998 that they did not have enough money to have the right types of food needed to maintain their health or simply did not have enough to eat.18 In the current study, there were no differences between responses of those in precompared with post-action stages for the statement related to food security. Since only about 16% agreed with the statement that their financial situation limits the amount of money spent on food, it may not be possible to detect the impact of income on stage distribution related to healthful eating. One hypothesis of the current study predicted that exercise was a possible gateway behavior for diet-related behaviors.The results in Table 5 show that those in the later stages for exercise (post-action) were more likely to be in the later stages of fruit and dairy product consumption behavior (post-action) but not for vegetable consumption or avoiding fat behaviors. Interrelationships were also found between exercise behavior and two dietary behaviors (avoiding fat and eating fiber) in older adults in another study1; however, the associations were weak, although the study population was large (N = 1615 over 65 years of age). It is interesting to note that national dietary intake data used to calculate the components of the Healthy Eating Index showed that older persons’ scores were lowest for daily servings of fruit and milk products compared with other components of the index.6 In the current study, those more likely to exercise were also more likely to report that they were in later stages of change for fruit and dairy product consumption, which is suggestive of having an adequate intake of fruit and dairy products. If the findings of the current study are confirmed by further longitudinal study, it may be helpful for educators to promote exercise behavior as a gateway behavior for some dietary behaviors. Table 5.
Relationship between Stage of Exercise and Stage of
Healthful Eating*,† Stage of Exercise Stage of Healthy Eating
Pre-action
Post-action
P Value
Dairy products (3+ servings/d) 1.62 ± 0.49
1.77 ± 0.42
.018
Fruit (2+ servings/d)
1.74 ± 0.44
1.91 ± 0.29
.001
Vegetables (3+ servings/d)
1.64 ± 0.48
1.72 ± 0.45
.271
Avoiding fat
1.68 ± 0.47
1.80 ± 0.40
.063
*N ranged from 72 to 73 for pre-action and 128 to 129 for post-action. Pre-action and post-action for stage of healthful eating were assigned numerical values of 1 and 2, respectively. † Values represent means ± SD. Post-action values are significantly different from pre-action values when P < .05 according to ANOVA.
STUDY LIMITATIONS AND LESSONS LEARNED The demographics of the convenience sample used in the current study are not representative; therefore, generalizability is limited, suggesting that further study is needed across ethnic groups. In future studies, dietary intake data should also be collected to confirm the accurate staging of individuals. However, in this preliminary study, the time taken to complete the survey (20 minutes) was felt to be overly burdensome for some subjects. In further studies, the completion of surveys could be limited to a shorter time over several data collection periods, allowing for the additional collection of dietary intake data. The results of the study indicate that there are positive relationships between stages of change for exercise, exercise selfefficacy, benefits of and barriers to exercise, and self-reported exercise for older adults. Positive relationships were also seen between self-efficacy for healthful eating behaviors and stage of change for healthful eating, with a less consistent overall relationship between the benefits of and barriers to healthful eating and stage of change for healthful eating behaviors. Stage of change results for all five of the behaviors in the current study indicated that the majority of the older adults in this study were in the maintenance stage followed by the precontemplation stage. This is a rather polar distribution, which indicates that the older adults were already well established in their behaviors. This information should be considered when planning and implementing nutrition and exercise programs focused on older adults. Exercise and dietary behaviors are both important components of a healthful lifestyle for older adults.19 The current study has shown that there is a potential gateway relationship between exercise and some dietary behaviors for this convenience sample of older adults participating in congregate dining programs. Little previous research has focused on the application of the TTM to identify gateway behaviors for healthful eating in older adults.1 Furthermore, no studies were found that applied the TTM in a longitudinal manner to confirm whether and how exercise may function as a gateway behavior for healthful eating in this population. Therefore, further longitudinal research involving a randomized controlled study should be designed to examine the eating behaviors of a group of older adults recently enrolled in an exercise program to demonstrate whether changes in eating behavior occurred after a change in stage of exercise behavior occurred.
ACKNOWLEDGMENT This research has been supported in part by the Minnesota Agricultural Experiment Station.
Journal of Nutrition Education and Behavior Volume 34 Supplement 1
REFERENCES 1. Nigg CR, Burbank PM, Padula C, et al. Stages of change across ten health risk behaviors for older adults. Gerontologist. 1999;39:473-482. 2. Rimer G, Orleans C, Fleisher L, et al. Does tailoring matter? Health Educ Res. 1994;9:69-84. 3. Marcus BH, Banspach SW, Lefebvre RC, Rossi JS, Carleton RA, Abrams DB. Using the stage of change model to increase the adoption of physical activity among community participants. Am J Health Promotion. 1992;6:424-429. 4. Greene GW, Rossi SR, Rossi JS, Velicer WF, Fava JL, Prochaska JO. Dietary applications of the stages of change model. J Am Diet Assoc. 1999;99:673-678. 5. US Dept of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 6. Federal Interagency Forum on Aging-Related Statistics. Report on older Americans 2000: key indicators of well-being. Available at: http://www.agingstats.gov/chartbook2000/healthrisks.html#Indicator 20. Accessed November 10, 2000. 7. Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998;98:548-553. 8. Brownson RC, Eyler AA, King AC, Brown AR, Shyu YL, Sallis JF. Patterns and correlates of physical activity among U.S. women 40 years and older. Am J Public Health. 2000;90:264-270. 9. Cardinal BJ. The stages of exercise scale and stages of exercise behavior in female adults. J Sports Med Phys Fitness. 1995;35:87-92.
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10. Campbell MK, Reynolds KD, Havas S, et al. Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-Day for Better Health community studies. Health Educ Behav. 1999;26:513-534. 11. Jones M, Nies MA.The relationship of perceived benefits of and barriers to reported exercise in older African American women. Publ Health Nurs. 1996;13:151-158. 12. Sharpe PA,Vaca VL, Sargent RG, White C, Gu J, Corwin SJ. A nutrition education program for older adults at congregate nutrition sites. J Nutr Educ Elderly. 1996;16:19-31. 13. Auld GW, Nitzke SA, McNulty J, et al.A stage-of-change classification system based on actions and beliefs regarding dietary fat and fiber. Am J Health Promotion. 1998;12:192-201. 14. Rhodes RE, Martin AD,Taunton JE, Rhodes EC, Donnelly M, Elliot J. Factors associated with exercise adherence among older adults. An individual perspective. Sports Med. 1999;28:397-411. 15. Herrick AB, Stone WJ, Mettler MM. Stages of change, decisional balance, and self-efficacy across four health behaviors in a worksite environment. Am J Health Promotion. 1997;12:49-56. 16. McAuley E. Self-efficacy and the maintenance of exercise participation in older adults. J Behav Med. 1993;16:103-113. 17. McAuley E, Lox C, Duncan TE. Long-term maintenance of exercise, self-efficacy, and physiological change in older adults. J Gerontol. 1993; 48:218-224. 18. US Bureau of the Census. Food Security Supplement to the Current Population Survey. Washington, DC: US Bureau of the Census; August 1998. 19. American Dietetic Association. Position of the American Dietetic Association: nutrition, aging, and the continuum of care. J Am Diet Assoc. 2000;100:580-595.
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Exercise as a Gateway Behavior for Healthful Eating among Older Adults: An Exploratory Study M I C H E L L E T U C K E R , MS; M A R L A R E I C K S , P H D, RD Department of Food Science and Nutrition, University of Minnesota, St. Paul, Minnesota 55108
INTRODUCTION
ABSTRACT
Nutrition and physical activity contribute to the health, selfsufficiency, and quality of life for older adults. Nutrition education interventions may be more effective in promoting positive and productive aging if attention is paid to the manner in which health behaviors are related. It has been suggested that there are potential gateway behaviors to health for older adults.1 A gateway behavior is a health behavior that, when positively changed, would cause a positive change in another health behavior. As gateway behaviors to health are identified for older adults, interventions could focus on only one or two key behaviors, and changes in other behaviors would ensue. Preliminary study using the Transtheoretical Model (TTM) has shown that the interrelationships between various health behaviors increase with age.1 The TTM has been successfully applied to older adults relative to smoking cessation,2 exercise,3 and multiple eating behaviors including avoiding fat, eating fiber, and losing weight.1 The TTM explains intentional exercise and eating behavior change based on movement through a series of stages.4 The stages include the precontemplation stage (the individual is not doing or intending to do the target behavior in the next 6 months), the contemplation stage (the individual intends to change but not soon), the preparation stage (the individual intends to change in the next month), the action stage (the individual actively engages in the new behavior for less than 6 months), and the maintenance stage (the individual has maintained the change in the target behavior for at least 6 months). In the earlier stages, the importance of the benefits and barriers to making behavior changes is considered. In the later stages, self-efficacy functions to help the individual make and maintain changes.Various processes of change are used by individuals as they progress through the stages focusing on thoughts, feelings, experiences, behaviors, and reinforcement. A recent surgeon general’s report5 advocates increasing levels of physical activity for older adults given the evidence for reduction of the risk of certain chronic diseases, maintenance of independent living, and enhancement of overall quality of life. National Health Interview Survey results have recently shown that the percentage of older persons who were sedentary declined between 1985 and 1995, from 34%
Context: The relationship between eating and exercise behavior change may influence effectiveness of interventions for older adults. Objective: To determine whether exercise is a potential gateway behavior for healthful eating behavior among older adults. Design: The Transtheoretical Model was applied to eating and exercise behaviors through the administration of a crosssectional survey. Setting/Participants: 205 older adults (the majority were white women) participating in congregate dining programs in a large Midwestern city. Variables Measured: Perceived benefits and barriers, self-efficacy, and stage of change related to exercise and eating habits Analysis: Differences in responses to survey items based on stage of change were determined by analysis of variance, P < .05. Results: Subjects in later stages for exercise behavior were also likely to be in later stages for eating adequate servings of fruit and dairy products but not for vegetables and avoiding fat. Conclusions and Implications: Exercise is a potential gateway behavior for some dietary behaviors for older adults, justifying further controlled, longitudinal research. KEY WORDS: way behavior
older adults,Transtheoretical Model, gate( J Nutr Educ Behav. 2002;S14-S19.)
This research has been supported in part by the Minnesota Agricultural Experiment Station. Address for correspondence: Marla Reicks, PhD, RD, Department of Food Science and Nutrition, University of Minnesota, 162 FScN, 1334 Eckles Avenue, St. Paul, MN 55108;Tel: (612) 624-4735; Fax: (612) 625-5272; E-mail: [email protected]. ©2002 SOCIETY FOR NUTRITION EDUCATION
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Journal of Nutrition Education and Behavior Volume 34 Supplement 1
to 28% among men and from 44% to 39% among women.6 Exercise behavior may be an ideal gateway behavior to changing eating behaviors as older adults realize benefits from being more physically active and desire to intensify these benefits by improving other health behaviors. The purpose of the current study was to apply the TTM to the exercise and eating habits of older adults in a preliminary manner in preparation for further longitudinal study. The hypotheses that were tested were (1) there are positive relationships between stage of exercise and healthful eating behaviors (eating adequate amounts of fruits, vegetables, and dairy products and avoiding fat), indicating that exercise is a potential gateway behavior for diet-related behaviors, and (2) there are positive relationships between stages of change, self-efficacy, and decisional balance (benefits and barriers) for exercise and healthful eating behaviors.
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Stage of exercise behavior response options was related to the question, “Do you exercise regularly according to the definition (regular exercise is any planned physical activity [eg, walking, low-impact aerobics, bicycling, swimming, etc] performed to increase physical fitness)?” Stage of eating behavior response options was related to the question, “Do you eat x number of servings of x food type on a typical day?” Possible response options were “Yes, I have been for more than 6 months” (maintenance), “Yes, I have been for less than 6 months” (action),“No, but I intend to in the next 30 days” (preparation), “No, but I intend to in the next 6 months” (contemplation), or “No, and I do not intend to in the next 6 months” (precontemplation). Because the stage distribution was bipolar, the precontemplation, contemplation, and preparation stages were combined into a pre-action stage, whereas the action and maintenance stages were combined into a post-action stage.
DESCRIPTION OF THE SURVEY DESCRIPTION OF THE SURVEY RESULTS A convenience sample of subjects (N = 205) was recruited from 11 dining sites for older adults managed by a volunteer association within a large Midwestern city and its surrounding suburbs. Dining sites were selected based on representation from inner city and suburban sites but did not include sites that catered specifically to immigrant populations or to less independent older adults living in high-rise buildings. The subjects were asked to provide consent to participate according to the Institutional Review Board Human Subjects Protection Committee prior to completing a self-administered survey either before or after a noon meal. The survey took approximately 20 minutes to complete, and a travel mug or stress ball was offered as a token of appreciation. Less than 10% of those participating in the meal at the selected dining sites refused to complete the survey. The survey was read to those who requested assistance. Survey items were developed based on the research questions and were adapted from other studies when appropriate. The items were related to demographic information, food security,7 self-reported exercise,8,9 stages of change,1 self-efficacy,10 and benefits and barriers related to exercise and healthy eating.11-13 The survey was pretested with older adults at a senior health fair in the same city to estimate the reliability of survey items and for clarity. Based on the results of the pilot test, questions were modified as needed. Cronbach coefficient was .58 for stage of eating behaviors, .84 for the perceived benefits to exercise, .76 for the perceived barriers to exercise, .72 for the perceived benefits to eating healthful meals, and .63 for the perceived barriers to eating healthful meals. Statistical analyses were performed using SAS software (Statistical Analysis Systems,Version 6.12, Cary, NC). Analysis of variance (ANOVA) was used to determine differences in responses to survey items based on stage of dietary behavior or stage of exercise. A significance level of P < .05 was considered significant.
Demographic data are summarized in Table 1. The sample consisted of 205 mostly white adults 65 years of age and older, with the majority of the population being female. Table 1.
Characteristics of Subjects* %
n
65-70
17.2
35
71-75
20.2
41
76-80
29.1
59
81-85
21.2
43
86-91+
12.3
25
Age, yr
Gender Male
31.5
64
Female
68.5
139
93.2
191
6.8
14
Ethnicity White African American Marital status Married Never married
29.7
60
5.4
11
Widowed
49.0
99
Divorced
15.8
32
Education level High school or less
47.0
95
Some or completed technical/vocational school
22.8
46
Some or completed college
22.3
45
7.0
16
Postgraduate Does current financial situation limit amount of money that can be spent on food? Yes
16.0
32
No
84.0
168
*N ranged from 200 to 205 among questions.
S16 Table 2.
Tucker and Reicks/EXERCISE AS A GATEWAY BEHAVIOR FOR HEALTHFUL EATING AMONG OLDER ADULTS Frequency Distribution across the Stages for Exercise and Consumption of Fruit, Vegetables, and Dairy Products and Avoiding Fat*
Stage
Precontemplation
Contemplation
Preparation
Action
Maintenance
Exercise
16.3 (33)
10.8 (22)
9.4 (19)
8.4 (17)
55.2 (112)
Avoiding fat
19.7 (40)
1.5 (3)
3.0 (6)
8.4 (17)
67.5 (137)
9.8 (20)
2.9 (6)
2.5 (5)
4.9 (10)
79.9 (163)
Vegetables (3+ servings/d)
16.7 (34)
3.9 (8)
9.9 (20)
2.5 (5)
67.0 (136)
Dairy products (3+ servings/d)
19.2 (39)
4.9 (10)
3.9 (8)
2.5 (5)
69.5 (141)
Fruit (2+ servings/d)
*Values represent percent of total N. The numbers in parentheses represent the n for each stage for each behavior.
Most of the population was either married or widowed. Almost half reported an education level of high school or less, whereas about one quarter had attended technical or vocational school or college. The majority did not indicate that they were financially limited in the amount of money they could spend on food. The distributions across the stages of change for exercise and healthy eating behaviors are presented in Table 2. Most of the subjects fell on the extreme ends for stages of health behavior change.The distribution of the participants in the stages of change for exercise shows that about half considered themTable 3.
selves to be in the maintenance stage and 16.3% considered themselves to be in the precontemplation stage. Nigg et al1 also found a similar bipolar distribution in stage of change for exercise for older adults compared with younger subjects, who were more evenly distributed across the stages.The polarity of the distribution in the stages of change for exercise would indicate that some have been exercising regularly for a long period of time, whereas others have not even considered exercising.The results in Table 2 show that many respondents also considered themselves to be in either the precontemplation or maintenance stages for healthful eating behaviors. Similar stage
Benefits and Barriers and Self-efficacy for Exercise and Reported Exercise by Stage*,†,‡ Stage of Exercise Pre-action
Post-action
Regular exercise is good for overall health.
3.89 ± 0.83
4.30 ± 0.81§
Exercise can improve strength and balance.
3.66 ± 0.99
4.22 ± 0.80§
Regular exercise would help have a more positive outlook on life.
3.41 ± 1.02
4.10 ± 0.92§
Easier to perform routine physical tasks if exercised regularly.
3.21 ± 1.03
3.80 ± 1.06§
Have more energy for friends/family if exercised regularly.
3.10 ± 0.99
3.68 ± 1.08§
Exercise is a good way to socialize with friends.
3.10 ± 1.06
3.48 ± 1.26§
Sleep more soundly if exercised regularly.
3.07 ± 1.09
3.43 ± 1.28§
Have physical limitations that make it difficult to exercise.
3.18 ± 1.47
2.40 ± 1.36§
Too much pain when exercising.
2.86 ± 1.25
2.06 ± 1.08§
Worry might fall or get hurt while exercising.
2.71 ± 1.31
1.98 ± 1.09§
Do not have time for regular exercise.
2.30 ± 1.01
1.84 ± 1.05§
Do not have any place to exercise.
2.07 ± 1.07
1.74 ± 0.97§
Too old to exercise regularly.
2.31 ± 1.28
1.74 ± 1.04§
Weight makes it difficult to exercise.
2.20 ± 1.04
1.72 ± 0.90§
2.14 ± 0.96
3.76 ± 0.93§
40.43 ± 98.03
173.84 ± 135.37§
108.04 ± 266.09
160.93 ± 343.81
Benefits/barriers to regular exercise
Self-efficacy Confident can exercise regularly Self-reported activity Time spent on planned physical activity, min Time spent on housework, min Time spent on volunteer activity, min Time spent on vigorous physical activity, min
79.46 ± 227.75
99.65 ± 189.82
3.45 ± 16.28
26.28 ± 73.86§
*N ranged from 68 to 74 for pre-action and 124 to 129 for post-action. † Benefits/barriers statement response options were on a scale of 1 to 5, where 1 = strongly disagree and 5 = strongly agree; self-efficacy was measured on a scale of 1 to 5, where 1 = not at all confident and 5 = completely confident. ‡ Values represent means ± SD. Section marks by post-action values indicate statistical significance compared to pre-action values at P < .05 according to ANOVA.
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that self-efficacy scores for exercise and perceived benefits and barriers to exercise were related to progress from precontemplation to maintenance stages for subjects with a mean age of 42 years. Confidence in one’s ability to maintain a regular exercise program was also found to be important for adherence to exercise programs for older adults.16,17 Table 3 shows the results related to the subjects’ self-reported amount of time spent on various types of activity. Those in the post-action stages were more likely to report greater time spent on planned or vigorous physical activity than those in the preaction stages. In general, most respondents agreed with the benefit statements and disagreed with the barrier statements for healthful eating behaviors (Table 4). Differences between perceptions of benefits and barriers by those in post- versus pre-action stages occurred for the stages of change for fruit and vegetable behavior more often than for the stages of change for dairy products or avoiding fat behaviors. For all eating behaviors, those in the post-action stages agreed more often with the benefit statement “I would feel better if I ate healthy meals” and disagreed more often with the barrier statement “Healthy meals cost too much to prepare” compared with those in the pre-action stages. Similar to the results related to exercise behavior, those in the post-action
distribution results were found for older adults by Nigg et al1 for low-fat and high-fiber changes and by Auld et al13 for lowfat eating behaviors.The perceptions of benefits and barriers to exercise in the current study are presented in Table 3 according to pre- or post-action stage of exercise.The results indicate that the most commonly held benefits of exercise were that it is good for overall health and improves strength and balance. Exercise as a way to socialize with friends or as a way to improve sleep was a less positively held benefit. The more commonly held barrier to exercise was having physical limitations or pain that makes it difficult to exercise, whereas the least commonly held barrier was being too old to exercise or that weight makes it difficult to exercise. Rhodes et al14 reviewed studies examining factors associated with exercise among older adults and found that the greatest perceived barriers were physical frailty and poor health. In the current study, agreement with each of the benefit statements was stronger for those individuals in the post-action compared with the preaction stages, whereas agreement with each of the barrier statements was weaker.There was also a significant difference in the level of self-confidence in the ability to exercise regularly between those classified in pre- versus post-action stage of exercise.This supports results in another study with a demographically different population group. Herrick et al15 found
Table 4.
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Benefits and Barriers and Self-efficacy for Healthful Eating and Diet-Related Items by Stage*,†,‡ Fruit Preaction
Vegetables Postaction
Preaction
Dairy
Postaction
Preaction
Avoiding Fat Postaction
Preaction
Postaction
Benefits/barriers to healthy meals Feel better
3.87 ± 0.67
4.21 ± 0.70§ 3.98 ± 0.59
4.24 ± 0.74§ 4.02 ± 0.77
4.21 ± 0.67§ 3.96 ± 0.91
4.23 ± 0.61§
More energy
3.68 ± 0.91
3.95 ± 0.94
3.80 ± 0.77
3.95 ± 1.00
3.95 ± 0.67
3.88 ± 1.02
3.71 ± 1.02
3.97 ± 0.90
Improves mental ability
3.03 ± 1.20
3.81 ± 0.99§ 3.61 ± 0.95
3.73 ± 1.11
3.77 ± 0.93
3.66 ± 1.11
3.49 ± 1.10
3.76 ± 1.04
Would not make a difference at my age
2.65 ± 1.11
2.54 ± 1.36
2.44 ± 1.35§ 2.53 ± 1.21
2.58 ± 1.36
2.94 ± 1.28
2.44 ± 1.31§
2.82 ± 1.22 2.77 ± 1.17
2.19 ± 1.13
§
Too much time to prepare
2.65 ± 1.08
2.32 ± 1.18
2.51 ± 1.05
2.32 ± 1.21
2.49 ± 1.17
2.33 ± 1.17
Do not taste very good
2.35 ± 1.20
1.80 ± 0.92§ 2.28 ± 1.14
1.72 ± 0.86§ 1.98 ± 0.95
1.86 ± 0.99
1.90 ± 0.80
1.88 ± 1.03
Cost too much to prepare
2.71 ± 1.13
1.98 ± 1.04§ 2.46 ± 1.06
1.93 ± 1.06§ 2.44 ± 1.07
1.97 ± 1.06§ 2.35 ± .99
2.01 ± 1.10§
On a diet recommended by a physician
1.67 ± 0.48
1.66 ± 0.49
1.75 ± 0.44
1.63 ± 0.50
1.64 ± 0.52
1.68 ± 0.47
1.93 ± 0.25
1.58 ± 0.51§
Financial situation limits the amount of money can spend on food
1.81 ± 0.40
1.84 ± 0.39
1.89 ± 0.32
1.81 ± 0.41
1.81 ± 0.40
1.84 ± 0.39
1.90 ± 0.31
1.81 ± 0.41
Number of meals eaten at home weekly
3.77 ± 1.31
3.94 ± 1.24
3.82 ± 1.42
3.94 ± 1.16
3.74 ± 1.28
3.97 ± 1.22
3.77 ± 1.26
3.97 ± 1.24
3.23 ± 0.97
3.84 ± 0.97§ 3.52 ± 1.04
3.83 ± 1.00§ 3.59 ± 1.13
3.81 ± 0.93
Diet-related items
Self-efficacy Confident can eat healthy meals regularly
3.86 ± 0.96§ 3.54 ± 0.97
*N ranged from 30 to 31 for pre-action and 167 to 173 for post-action for fruit, 60 to 62 for pre-action and 138 to 141 for vegetables, 55 to 57 for pre-action and 141 to 146 for post-action for dairy, and 46 to 49 for pre-action and 150 to 154 for post-action for cutting fat. † Benefits/barriers statement response options were on a scale of 1 to 5, where 1 = strongly disagree and 5 = strongly agree. For diet-related items, response options were on a diet recommended by a physician and financial situation limits money spent on food, 1 = yes, 2 = no; number of meals eaten at home weekly, < 1 = 1; 1-5 = 2; 6-10 = 3; 11-15 = 4; 16-20 = 5; > 20 = 6; and self-efficacy, 1 = not at all confident and 5 = completely confident. ‡ Values represent means ± SD. Section marks (§) by post-action values indicate statistical significance compared with pre-action values at P < .05 according to ANOVA.
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Tucker and Reicks/EXERCISE AS A GATEWAY BEHAVIOR FOR HEALTHFUL EATING AMONG OLDER ADULTS
stages for fruit, vegetable, and dairy product behaviors were more likely to report a higher level of confidence in their ability to eat healthful meals on a regular basis compared with those in the pre-action stages for these behaviors. Older persons may have problems consistently obtaining a nutritious diet given that about 1.6 to 2 million elderly households reported in 1998 that they did not have enough money to have the right types of food needed to maintain their health or simply did not have enough to eat.18 In the current study, there were no differences between responses of those in precompared with post-action stages for the statement related to food security. Since only about 16% agreed with the statement that their financial situation limits the amount of money spent on food, it may not be possible to detect the impact of income on stage distribution related to healthful eating. One hypothesis of the current study predicted that exercise was a possible gateway behavior for diet-related behaviors.The results in Table 5 show that those in the later stages for exercise (post-action) were more likely to be in the later stages of fruit and dairy product consumption behavior (post-action) but not for vegetable consumption or avoiding fat behaviors. Interrelationships were also found between exercise behavior and two dietary behaviors (avoiding fat and eating fiber) in older adults in another study1; however, the associations were weak, although the study population was large (N = 1615 over 65 years of age). It is interesting to note that national dietary intake data used to calculate the components of the Healthy Eating Index showed that older persons’ scores were lowest for daily servings of fruit and milk products compared with other components of the index.6 In the current study, those more likely to exercise were also more likely to report that they were in later stages of change for fruit and dairy product consumption, which is suggestive of having an adequate intake of fruit and dairy products. If the findings of the current study are confirmed by further longitudinal study, it may be helpful for educators to promote exercise behavior as a gateway behavior for some dietary behaviors. Table 5.
Relationship between Stage of Exercise and Stage of
Healthful Eating*,† Stage of Exercise Stage of Healthy Eating
Pre-action
Post-action
P Value
Dairy products (3+ servings/d) 1.62 ± 0.49
1.77 ± 0.42
.018
Fruit (2+ servings/d)
1.74 ± 0.44
1.91 ± 0.29
.001
Vegetables (3+ servings/d)
1.64 ± 0.48
1.72 ± 0.45
.271
Avoiding fat
1.68 ± 0.47
1.80 ± 0.40
.063
*N ranged from 72 to 73 for pre-action and 128 to 129 for post-action. Pre-action and post-action for stage of healthful eating were assigned numerical values of 1 and 2, respectively. † Values represent means ± SD. Post-action values are significantly different from pre-action values when P < .05 according to ANOVA.
STUDY LIMITATIONS AND LESSONS LEARNED The demographics of the convenience sample used in the current study are not representative; therefore, generalizability is limited, suggesting that further study is needed across ethnic groups. In future studies, dietary intake data should also be collected to confirm the accurate staging of individuals. However, in this preliminary study, the time taken to complete the survey (20 minutes) was felt to be overly burdensome for some subjects. In further studies, the completion of surveys could be limited to a shorter time over several data collection periods, allowing for the additional collection of dietary intake data. The results of the study indicate that there are positive relationships between stages of change for exercise, exercise selfefficacy, benefits of and barriers to exercise, and self-reported exercise for older adults. Positive relationships were also seen between self-efficacy for healthful eating behaviors and stage of change for healthful eating, with a less consistent overall relationship between the benefits of and barriers to healthful eating and stage of change for healthful eating behaviors. Stage of change results for all five of the behaviors in the current study indicated that the majority of the older adults in this study were in the maintenance stage followed by the precontemplation stage. This is a rather polar distribution, which indicates that the older adults were already well established in their behaviors. This information should be considered when planning and implementing nutrition and exercise programs focused on older adults. Exercise and dietary behaviors are both important components of a healthful lifestyle for older adults.19 The current study has shown that there is a potential gateway relationship between exercise and some dietary behaviors for this convenience sample of older adults participating in congregate dining programs. Little previous research has focused on the application of the TTM to identify gateway behaviors for healthful eating in older adults.1 Furthermore, no studies were found that applied the TTM in a longitudinal manner to confirm whether and how exercise may function as a gateway behavior for healthful eating in this population. Therefore, further longitudinal research involving a randomized controlled study should be designed to examine the eating behaviors of a group of older adults recently enrolled in an exercise program to demonstrate whether changes in eating behavior occurred after a change in stage of exercise behavior occurred.
ACKNOWLEDGMENT This research has been supported in part by the Minnesota Agricultural Experiment Station.
Journal of Nutrition Education and Behavior Volume 34 Supplement 1
REFERENCES 1. Nigg CR, Burbank PM, Padula C, et al. Stages of change across ten health risk behaviors for older adults. Gerontologist. 1999;39:473-482. 2. Rimer G, Orleans C, Fleisher L, et al. Does tailoring matter? Health Educ Res. 1994;9:69-84. 3. Marcus BH, Banspach SW, Lefebvre RC, Rossi JS, Carleton RA, Abrams DB. Using the stage of change model to increase the adoption of physical activity among community participants. Am J Health Promotion. 1992;6:424-429. 4. Greene GW, Rossi SR, Rossi JS, Velicer WF, Fava JL, Prochaska JO. Dietary applications of the stages of change model. J Am Diet Assoc. 1999;99:673-678. 5. US Dept of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 6. Federal Interagency Forum on Aging-Related Statistics. Report on older Americans 2000: key indicators of well-being. Available at: http://www.agingstats.gov/chartbook2000/healthrisks.html#Indicator 20. Accessed November 10, 2000. 7. Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998;98:548-553. 8. Brownson RC, Eyler AA, King AC, Brown AR, Shyu YL, Sallis JF. Patterns and correlates of physical activity among U.S. women 40 years and older. Am J Public Health. 2000;90:264-270. 9. Cardinal BJ. The stages of exercise scale and stages of exercise behavior in female adults. J Sports Med Phys Fitness. 1995;35:87-92.
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10. Campbell MK, Reynolds KD, Havas S, et al. Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-Day for Better Health community studies. Health Educ Behav. 1999;26:513-534. 11. Jones M, Nies MA.The relationship of perceived benefits of and barriers to reported exercise in older African American women. Publ Health Nurs. 1996;13:151-158. 12. Sharpe PA,Vaca VL, Sargent RG, White C, Gu J, Corwin SJ. A nutrition education program for older adults at congregate nutrition sites. J Nutr Educ Elderly. 1996;16:19-31. 13. Auld GW, Nitzke SA, McNulty J, et al.A stage-of-change classification system based on actions and beliefs regarding dietary fat and fiber. Am J Health Promotion. 1998;12:192-201. 14. Rhodes RE, Martin AD,Taunton JE, Rhodes EC, Donnelly M, Elliot J. Factors associated with exercise adherence among older adults. An individual perspective. Sports Med. 1999;28:397-411. 15. Herrick AB, Stone WJ, Mettler MM. Stages of change, decisional balance, and self-efficacy across four health behaviors in a worksite environment. Am J Health Promotion. 1997;12:49-56. 16. McAuley E. Self-efficacy and the maintenance of exercise participation in older adults. J Behav Med. 1993;16:103-113. 17. McAuley E, Lox C, Duncan TE. Long-term maintenance of exercise, self-efficacy, and physiological change in older adults. J Gerontol. 1993; 48:218-224. 18. US Bureau of the Census. Food Security Supplement to the Current Population Survey. Washington, DC: US Bureau of the Census; August 1998. 19. American Dietetic Association. Position of the American Dietetic Association: nutrition, aging, and the continuum of care. J Am Diet Assoc. 2000;100:580-595.
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