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AHA Scientific Statement
Interventions to Promote Physical Activity and DietaryLifestyle Changes for Cardiovascular Risk Factor Reduction
in AdultsA Scientific Statement From the American Heart Association
Endorsed by the Preventive Cardiovascular Nurses Association and the Society ofBehavioral Medicine
Nancy T. Artinian, PhD, RN, FAHA, Chair; Gerald F. Fletcher, MD, FAHA, Co-Chair;Dariush Mozaffarian, MD, DrPH, FAHA; Penny Kris-Etherton, PhD, RD, FAHA;
Linda Van Horn, PhD, RD, FAHA; Alice H. Lichtenstein, DSc, FAHA;Shiriki Kumanyika, PhD, MPH, FAHA; William E. Kraus, MD, FAHA; Jerome L. Fleg, MD, FAHA;
Nancy S. Redeker, PhD, RN, FAHA; Janet C. Meininger, PhD, RN; JoAnne Banks, RN, PhD;Eileen M. Stuart-Shor, PhD, ANP, FAHA; Barbara J. Fletcher, RN, MN, FAHA;
Todd D. Miller, MD, FAHA; Suzanne Hughes, MSN, RN, FAHA; Lynne T. Braun, PhD, CNP, FAHA;Laurie A. Kopin, MS, RN, ANP, FPCNA; Kathy Berra, MSN, ANP, FAHA;
Laura L. Hayman, PhD, RN, FAHA; Linda J. Ewing, PhD, RN; Philip A. Ades, MD;J. Larry Durstine, PhD; Nancy Houston-Miller, BSN, FAHA;
Lora E. Burke, PhD, MPH, FAHA, Steering Committee Co-Chair; on behalf of the American HeartAssociation Prevention Committee of the Council on Cardiovascular Nursing
Approximately 79 400 000 American adults, or 1 in 3, havecardiovascular disease (CVD).1 CVD accounts for 36.3%
or 1 of every 2.8 deaths in the United States and is the leadingcause of death among both men and women in the United States,killing an average of 1 American every 37 seconds.1 Olderadults, some ethnic minority populations, and socioeconomicallydisadvantaged individuals have an increased prevalence of CVDand vascular/metabolic risk factors such as hypertension, dys-lipidemia, and diabetes; are more likely to have �2 risk factors;and are at increased risk of being sedentary, overweight orobese, and having unhealthy dietary habits.2–10 Black and His-panic immigrants are initially at lower risk for vascular/metabolicrisk factors and CVD than US-born black and Hispanic individu-als,2 but as they adapt to the diet and activity habits of this country,
the prevalence of vascular/metabolic risk factors increases.3 Each ofthese issues emphasizes the importance of interventions to promotephysical activity (PA) and healthy diets in all American adults.
Even modest sustained lifestyle changes can substantiallyreduce CVD morbidity and mortality. Because many of thebeneficial effects of lifestyle changes accrue over time,long-term adherence maximizes individual and populationbenefits. Interventions targeting dietary patterns, weight re-duction, and new PA habits often result in impressive rates ofinitial behavior changes, but frequently are not translated intolong-term behavioral maintenance.4 Both adoption and main-tenance of new cardiovascular risk-reducing behaviors posechallenges for many individuals. According to the NationalCenter for Health Statistics, life expectancy could increase by
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are requiredto complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May 4, 2010. A copy of thestatement is available at http://www.americanheart.org/presenter.jhtml?identifier�3003999 by selecting either the “topic list” link or the “chronologicallist” link (No. KB-0043). To purchase additional reprints, call 843-216-2533 or e-mail [email protected].
The American Heart Association requests that this document be cited as follows: Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van HornL, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, BraunLT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine L, Houston-Miller N, Burke LE; on behalf of the American Heart AssociationPrevention Committee of the Council on Cardiovascular Nursing. Interventions to promote physical activity and dietary lifestyle changes forcardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122:406–441.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,visit http://www.americanheart.org/presenter.jhtml?identifier�3023366.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier�4431. A link to the “Permission Request Form” appears on the right side of the page.
(Circulation. 2010;122:406-441.)© 2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e3181e8edf1
406
almost 7 years if all forms of major CVD were eliminated.5
Improvements in morbidity and quality of life would also besubstantial. In order to achieve these goals, healthcare pro-viders must focus on reducing CVD risk factors such asoverweight and obesity, poor dietary habits, and physicalinactivity by helping individuals begin and maintain dietaryand PA changes. Each year �$44 billion, including $33billion in medical costs and $9 billion in lost productivity dueto heart disease, cancer, stroke, and diabetes, is attributable topoor nutrition.6 In the year 2000, the annual estimated directmedical cost of physical inactivity was $76.6 billion.1
There are considerable published data to strongly support thebenefits of PA and dietary changes as a means to decrease themorbidity and mortality of CVD and stroke in adults. Such dataare presented and discussed in detail in the statements from theAmerican Heart Association (AHA)7 and other sources. Notablestatements and studies include, but are not limited to, thestatement on exercise (AHA),8 the statement on PA interventionstudies (AHA),9 the statement on diet and lifestyle recommen-dations (AHA),10 the 2005 Dietary Guidelines for Americans,11
and the recommendation on PA and public health.12 Despite theabundance of data supporting the benefits of lifestyle changesfor CVD, it is striking that Americans are increasingly morechallenged with the growing burdens of excess body weight,limited PA, and suboptimal dietary habits. These lifestyle prob-lems are also associated with many chronic diseases other thanCVD and stroke, including type 2 diabetes, osteoporosis, depres-sion, and many cancers.
Cardiovascular risk factors can be combated and controlledby adherence to current lifestyle recommendations. Oneimportant example of success achieved in improving lifestylehabits is the achieved decline in prevalent tobacco use from42.4% to 20.5% of American adults between 1965 and2007.13 Although work remains in this regard, the success oftobacco cessation efforts provides a strong basis for optimismthat a concerted evidence-based program of education, policychange, and individual interventions could successfully im-prove dietary and PA habits in the United States.
The purpose of this scientific statement is to provideevidence-based recommendations on implementing PA anddietary interventions among adult individuals, includingadults of racial/ethnic minority and/or socioeconomicallydisadvantaged populations. The most efficacious and effec-tive strategies are summarized, and guidelines are provided totranslate these strategies into practice. Individual, provider,and environmental factors that may influence the design ofthe interventions, as well as implications for policy and forfuture research, also are briefly addressed.
Description of Data Search Strategies andEvidence Rating SystemTo identify articles concerned with diet and PA behavior changeinterventions in individuals, literature searches were performedin 5 databases; MEDLINE, CINAHL, Cardiosource ClinicalTrials, Cochrane Library, and PsycINFO. Included studies werelimited to adult humans (defined as �18 years of age); Englishlanguage; randomized controlled or quasi-experimental designsor meta-analyses; focused on the effects of diet or PA interven-tions on weight, blood pressure (BP), PA level, aerobic resis-
tance exercise, fitness, or consumption of calories, fruits, vege-tables, fiber, total fat, saturated fat, cholesterol or salt; andpublished between January 1997 and May 2007. A few land-mark studies that predate 1997 publication were included in ourreview. Despite extensive search efforts, all relevant studies maynot have been identified; overall studies are representative andcapture the state of the field.
Unpublished reports or reports published only in abstract formwere not included. There was considerable variation in thedirection and strength of findings within the studies reviewed;however, an effect of bias against publication of studies with nullresults cannot be ruled out. Studies were restricted to thoseconducted in the United States because societal and culturalfactors can affect feasibility and success of particular interven-tion strategies; nonetheless, most of the findings may be gener-alizable to other developed nations. Feeding trials, observationalstudies of specific nutrients, and observational studies of aerobiccapacity were excluded. Given the varying goals and outcomesof the different identified intervention studies, when possible weused a common measure of effect size (ES) to quantify andcompare the success of each intervention.14 Recommendationsfollow the AHA and the American College of Cardiologymethods of classifying the evidence (Table 1).
FindingsDetails of studies of behavioral change interventions andrelated PA and dietary outcomes are presented in Tables 2and 3. Because cognitive-behavioral strategies for promotingchange are integrated across all reports, the studies in Tables2 and 3 are organized according to the format of theintervention delivery. The majority of studies assessedchanges in body weight and/or specific eating patterns (fruits/vegetables, dietary fat). Except for studies using standard behav-ioral interventions for weight loss, in which daily calorie and fatgram goals are provided, most studies did not target total energyintake. As shown in Tables 2 and 3, the ES for the between-
Table 1. Definition of Classes and Levels of Evidence Used inDietary and Physical Activity Lifestyle ChangesRecommendations226
Class I Conditions for which there is evidence for and/orgeneral agreement that the procedure or treatment
is useful and effective.
Class II Conditions for which there is conflicting evidenceand/or divergence of opinion about the
usefulness/efficacy of a procedure or treatment.
Class IIa Weight of evidence or opinion is in favor of theprocedure or treatment.
Class IIb Usefulness/efficacy is less well established byevidence or opinion.
Class III Conditions for which there is evidence and/orgeneral agreement that the procedure or treatmentis not useful/effective and in some cases may be
harmful.
Level of Evidence A Data derived from multiple randomized clinical trials.
Level of Evidence B Data derived from a single randomized trial ornonrandomized studies.
Level of Evidence C Expert opinion or case studies.
Artinian et al Promoting Physical Activity and Dietary Changes 407
Tabl
e2.
RCTs
ofIn
terv
entio
nsto
Prom
ote
PAan
dDi
etar
yLi
fest
yle
Chan
ge:N
onm
inor
itySa
mpl
es
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Prin
t-on
lyde
liver
yst
rate
gies
Hunt
etal
,118
2004
,2-
grou
pRC
T/12
mo
(N�
5473
)
Prim
ary
care
prac
tice
subj
ects
with
mild
lyco
ntro
lled
HTN,
58%
wom
en,
mea
nag
e69
y,�
90%
whi
te.
Rete
ntio
n:52
%.
I:2
educ
atio
nalp
acke
tsse
nt3
mo
apar
t;fir
stfo
cuse
don
HTN
and
lifes
tyle
,se
cond
onm
edic
atio
nad
here
nce
and
hom
eBP
mon
itorin
gw
ithBP
log;
both
incl
uded
lette
rfro
mPC
P.Su
bjec
tsfro
mbo
thgr
oups
rand
omly
sele
cted
toha
veBP
mea
sure
dan
dco
mpl
ete
surv
ey.I
nter
vent
ion
grou
psc
ored
high
eron
HTN
know
ledg
equ
iz(7
.48�
1.6
vs7.
06�
1.6,
P�0.
019)
.C:
Subj
ects
rece
ived
usua
lcar
e.
……
…BP
:C
137/
77vs
I135
/77,
P�0.
229.
Mar
cus
etal
,79
1998
,2-
grou
pRC
T/6
mo
(N�
194)
76%
fem
ale,
mea
nag
e44
.3y,
93.8
%w
hite
,82
%em
ploy
ed,
mea
n12
.5m
inof
mod
erat
ele
velP
Aat
base
line.
C:4
self-
help
book
lets
prom
otin
gPA
mai
led
tosu
bjec
ts.
I:Co
mpu
ter-
gene
rate
d,in
divi
dual
lyta
ilore
dre
ports
and
self-
help
man
uals
mat
ched
tost
age
ofm
otiv
atio
nalr
eadi
ness
.Re
ports
cons
iste
dof
feed
back
abou
t(1
)st
age
ofre
adin
ess
for
PA;
(2)
leve
lof
self-
effic
acy,
deci
sion
alba
lanc
e,an
dus
eof
cogn
itive
-beh
avio
ralp
roce
sses
;(3
)co
mpa
rativ
efe
edba
ck;
and
(4)
prog
ress
sinc
ela
stas
sess
men
t.M
otiv
atio
nally
mat
ched
man
uals
acco
mpa
nied
repo
rts;
sent
bym
ail.
…PA
:Igr
oup:
mea
nof
97.6
min
ofPA
/wk
com
pare
dw
ithIg
roup
(151
.4m
in/w
k);A
signi
fican
tlygr
eate
rnum
bero
fIsu
bjec
tsre
ache
dre
com
men
ded
PAth
anC
grou
p.
……
Grou
p-ba
sed
inte
rven
tion
deliv
ery
stra
tegi
es
Alda
naet
al,11
3
2006
,2-
grou
pRC
T/6
mo
(N�
348)
70%
wom
en,
mea
nag
e50
y,93
%w
hite
,BM
I31
–33.
Rete
ntio
n:In
terv
entio
n88
%,
cont
rol9
5%.
I:40
-lect
ure
cour
seov
er4
wks
,fo
cus
onnu
tritio
nan
dPA
.Te
xtbo
okan
dw
orkb
ook
follo
wed
curr
icul
umto
pics
prov
ided
,in
clud
edas
sign
men
ts.
Only
with
in-g
roup
chan
ges
repo
rted,
allP
valu
essi
gnifi
cant
.C:
Not
desc
ribed
.
……
Wei
ght
loss
:C
�0.
5vs
I�4.
5kg
,P�
0.00
01.
SBP/
DBP
mm
Hg:
�5/
�5.
5vs
�4/
�3.
8,P�
0.00
01Ch
oles
tero
l:�
6vs
�11
,P�
0.00
4Gl
ucos
e:�
3vs
�1,
P�0.
005.
Ande
rsen
etal
,56
1999
,2-
grou
pRC
T/1
y(N
�40
)
Wom
en,
mea
nag
e43
y;BM
I32.
9.Re
tent
ion:
98%
at16
wks
,82
.5%
at68
wks
.
Stru
ctur
edae
robi
cex
erci
se(S
AE)�
low
-fat
diet
:w
eekl
yae
robi
cex
erci
secl
asse
sfo
r16
wks
.M
oder
ate
lifes
tyle
activ
ity�
low
-fat
diet
:w
eekl
ygr
oup
sess
ions
focu
sed
onm
oder
ate
PA,
kept
daily
reco
rds,
wor
epe
dom
eter
s,re
ceiv
edgr
aphs
ofPA
and
feed
back
.
……
Wei
ght
loss
:SA
Egr
oup
�8.
3kg
vs�
7.9
kgat
16w
ks,
P�0.
08;
ES�
0.57
.At
1ye
ar,
SAE
rega
ined
1.6
vs0.
08kg
.
SBP,
chol
este
roli
mpr
ovem
ent
with
ingr
oups
(P�
0.00
1)at
16w
ks,
NSD
betw
een
grou
ps.
Burk
eet
al,24
2006
,4-
grou
pRC
T/18
mo
(N�
182)
87%
wom
en,
mea
nag
e44
y,29
.7%
min
ority
,BM
I34.
Rete
ntio
n:86
%.
Stan
dard
beha
vior
alw
eigh
tlo
sstre
atm
ent
(SBT
)de
liver
edto
all4
grou
ps:
(1)
SBT�
lact
o-ov
o-ve
g(L
OV)
diet
/not
pref
erre
d,(2
)SB
T�LO
Vdi
et/p
refe
rred
,(3
)SB
T�st
anda
rdw
eigh
tlo
ssdi
et/n
otpr
efer
red,
(4)
SBT�
stan
dard
wei
ght
loss
diet
/pre
ferr
ed.
SBT
incl
udes
goal
setti
ng,
self-
mon
itorin
g,an
dfe
edba
ck.
Inte
rven
tion
12m
o,st
udy
give
s6-
mo
repo
rt.
……
Wei
ght
loss
bydi
etgr
oups
:�
7.0–
7.5
kg,
NSD
bydi
etor
pref
eren
cegr
oup;
ES�
0.03
.
LDL:
SBT
0.05
vsSB
T�LO
V–0
.16,
P�0.
013.
Care
lset
al,23
2004
,2-
grou
pRC
T/1
y(N
�44
)
100%
wom
en,
mea
nag
e54
.7y,
race
not
repo
rted,
44.5
%co
llege
degr
ee,
33.3
%in
com
e�
$30
000,
mea
nBM
I36.
4.
Life
styl
ech
ange
(LC)
:24
grou
pse
ssio
nsto
chan
gew
eigh
tan
dPA
;5
com
pone
nts:
lifes
tyle
,ex
erci
se,
attit
udes
,re
latio
nshi
ps,
and
nutri
tion.
Focu
sed
onse
lf-m
onito
ring,
cont
rolli
ngst
imul
i,PA
,nu
tritio
ned
ucat
ion,
mod
ifyin
gse
lf-de
feat
ing
thou
ghts
and
nega
tive
emot
ions
,se
tting
real
istic
goal
s,re
latio
nshi
ps,
rela
pse
prev
entio
n,an
dw
eigh
tm
aint
enan
ce.
Life
styl
ech
ange
�se
lf-co
ntro
lski
llstra
inin
g:Li
fest
yle
chan
geas
abov
epl
usa
com
bina
tion
ofdi
dact
icin
stru
ctio
n,in
divi
dual
activ
ities
,an
dw
eekl
you
t-of
-cla
ssas
sign
men
tsto
stre
ngth
ense
lf-co
ntro
l.
Calo
ries:
Aver
age
daily
calo
ricin
take
decr
ease
d47
2ca
lin
both
grou
ps,
P�0.
05.
Perc
ent
ofen
ergy
from
fat
and
satu
rate
dfa
tde
crea
sed
by5.
4%an
d2.
7%,
resp
ectiv
ely;
P�0.
05.
NSD
betw
een
grou
ps.
PAan
dfit
ness
:bo
thgr
oups
incr
ease
dm
axim
alox
ygen
cons
umpt
ion,
tread
mill
time,
and
wee
kly
leis
ure
time
activ
ityP�
0.05
.NS
Dbe
twee
ngr
oups
.
Wei
ght
loss
:M
ean
wei
ght
loss
inbo
thgr
oups
was
6.2
kg,
P�0.
05.
NSD
betw
een
grou
ps.
BP:B
oth
grou
psha
da
mea
nde
crea
sein
SBP
of8
mm
Hgan
din
DBP
of7.
9m
mHg
,P�
0.05
.NSD
betw
een
grou
ps.
Chol:
Forb
oth
grou
psLD
Lde
crea
sed
anav
erag
eof
10.6
mg/
dL.N
SDbe
twee
ngr
oups
.
(Con
tinue
d)
408 Circulation July 27, 2010
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Hesh
kaet
al,12
3,12
4
2003
,2-
grou
p,m
ultic
ente
rRC
T/2
y(N
�42
3)
�80
%w
omen
,ag
e44
–45
y,BM
I34.
Self-
help
prog
ram
(SH)
:tw
o20
-min
coun
selin
gse
ssio
nsw
ithnu
tritio
nist
and
prov
isio
nof
self-
help
reso
urce
s.Co
mm
erci
alw
eigh
tlo
sspr
ogra
m:
food
and
activ
itypl
ans,
cogn
itive
rest
ruct
urin
gbe
havi
orm
odifi
catio
npl
an,
wee
kly
mee
tings
over
104
wks
.
……
Wei
ght
loss
:SH
grou
p�
1.3
vsCo
mm
erci
algr
oup
�4.
3kg
,P�
0.00
1at
12m
o;�
0.2
vs�
2.9
kgat
2y,
P�0.
001;
ES�
0.16
.
…
Jaki
cic
etal
,109
1999
,3-
grou
pRC
T/18
mo
(N�
148)
Wom
en,
mea
nag
e37
y,BM
I32.
8.Re
tent
ion:
78%
.
Beha
vior
alw
eigh
tco
ntro
lpro
gram
com
bine
dw
ith(1
)Lo
ng-b
out
exer
cise
(LB)
;(2
)m
ultip
lesh
ort-
bout
exer
cise
(SB)
;or
(3)
mul
tiple
shor
t-bo
utex
erci
sew
ithho
me
exer
cise
equi
pmen
t(S
BEQ)
(pro
vide
dtre
adm
ill).
…VO
2si
gnifi
cant
lyin
crea
sed
com
pare
dw
ithba
selin
e,NS
Dam
ong
grou
ps.
Wei
ght
loss
inSB
EQ�
7.4
kgvs
SB�
3.7,
P�0.
05;
NSD
from
LBgr
oup
�5.
8;ES
�16
.
…
Jeffe
ryet
al,25
1998
,5-
grou
pRC
T/18
mo
(N�
193)
�80
%fe
mal
e,ag
e�
40y,
�80
%w
hite
,BM
I31.
Rete
ntio
n:78
%.
(1)
Stan
dard
beha
vior
alth
erap
yfo
rw
eigh
tlo
ss(S
BT);
(2)
SBT�
supe
rvis
edw
alks
(SW
)3/
wk;
(3)
SBT�
SW�
pers
onal
train
er(P
T)w
orke
dw
ith2–
3su
bjec
tsdu
ring
wal
ks;
(4)
SBT�
SW�
mon
etar
yin
cent
ives
(I)pa
id$1
–$5
for
wal
ks(In
);an
d(5
)SB
T�SW
�PT
�In
rece
ived
allo
fth
eab
ove.
SBT�
wee
kly
grou
pse
ssio
ns�
24,
mon
thly
ther
eafte
rfo
r1
y.Da
ilyca
lorie
/fat
goal
s,PA
250–
1000
kcal
/wk.
…PA
:su
bjec
tsin
allg
roup
sac
hiev
edst
udy
goal
of10
00kc
al/w
k.
Wei
ght
loss
inkg
:SB
T�
7.6
vsSB
T�SW
�3.
8vs
SBT�
SW�
PT�
2.9
vsSB
T�SW
�I�
4.5
vsSB
T�SW
�PT
�I�
5.1
kg,
Trea
tmen
tgr
oups
diffe
renc
efro
mba
selin
eto
18m
ow
assi
gnifi
cant
,P�
0.03
.Th
eSB
Tgr
oup
had
grea
ter
loss
es.
…
Writ
ing
Grou
pof
the
PREM
IER
Colla
bora
tive
Rese
arch
Grou
p,26
2003
,3-
grou
pRC
T/6
mo
(N�
810)
Adul
tsw
ithst
age
1hy
perte
nsio
nor
optim
alBP
,34
%bl
ack,
62%
wom
en,
mea
nag
e50
year
s,ap
prox
imat
ely
10%
�$3
000
0an
nual
inco
me.
Subj
ects
’go
als
for
EST
and
EST�
DASH
wer
ew
eigh
tlo
ss�
15lb
for
subj
ects
with
BMI�
25,
�18
0m
inut
es/w
km
oder
ate
inte
nsity
PA,
daily
inta
keof
�10
0m
EqNa
,da
ilyin
take
�1
ozal
coho
lfor
men
and
1 ⁄2oz
for
wom
en.
Esta
blis
hed
(EST
):18
face
-to-
face
cont
acts
(14
grou
pm
eetin
gsan
d4
indi
vidu
alse
ssio
ns).
Diar
ies
used
tore
cord
PA,
calo
ries,
and
Na.
Esta
blis
hed
plus
DASH
(EST
�DA
SH):
Subj
ects
rece
ived
alli
nES
Tpl
usin
stru
ctio
nan
dco
unse
ling
abou
tDA
SHdi
et;
diet
ary
goal
sfo
rF/
V,lo
w-f
atda
iry,
satu
rate
dfa
t,an
dto
talf
at.
Diar
ies
used
tore
cord
PA,
calo
rie,
Na,
F/V,
dairy
,an
dfa
t.Ad
vice
only
(A):
Diet
itian
prov
ided
a30
-min
indi
vidua
lses
sion
onno
npha
rmac
olog
ical
fact
ors
that
affe
ctBP
and
prov
ided
prin
ted
educ
atio
nal
mat
eria
ls.Co
unse
ling
onbe
havio
rch
ange
notp
rovid
edbu
thad
4in
divid
ual
coun
selin
gse
ssio
nson
lifes
tyle
chan
ge.
DASH
diet
incl
uded
9–12
serv
ings
F/V
per
day,
low
-fatd
airy
2–3
serv
ings
/d,
�7%
ener
gysa
tura
ted
fat,
and
�25
%en
ergy
tota
lfat
.
F/V
serv
ings
/d:
Chan
gefro
mba
selin
e,0.
5fo
rA,
0.5
for
EST,
3.0
for
EST�
DASH
.ES
Tvs
A,P�
0.79
;al
loth
erco
mpa
rison
sP�
0.00
1.To
talf
at,
%kc
al:
�1.
0fo
rA,
�3.
9fo
rES
T,�
9.5
EST�
DASH
.Al
lcom
paris
ons
P�0.
001.
PAkc
al/k
g/d:
NSD.
Wei
ght
loss
:Ch
ange
from
base
line:
�1.
1kg
inA,
�4.
9kg
inES
T,�
5.8
kgin
EST�
DASH
;ES
Tvs
Aan
dES
T�DA
SHvs
A,P�
0.00
1;ES
Tvs
EST�
DASH
,P�
0.07
.
Prev
alen
ceof
high
BPat
6m
o:26
%in
Agr
oup,
17%
inES
Tgr
oup,
12%
inES
T�DA
SHgr
oup
(diff
eren
cebe
twee
nA
and
EST,
P�0.
01;
betw
een
Aan
dES
T�DA
SH,
P�0.
001;
betw
een
EST
and
EST�
DASH
,P�
0.12
).
McM
anus
etal
,27
2001
,2-
grou
pRC
T/18
mo
(N�
101)
�90
%fe
mal
e,m
ean
age
44y,
�88
%w
hite
,BM
I34.
Rete
ntio
n:20
%vs
54%
at18
mo.
Low
-fat
(LF)
diet
:20
%of
kcal
.M
oder
ate
fat
(MF)
:35
%of
kcal
,M
edite
rran
ean
diet
.Bo
thgr
oups
:w
eekl
ygr
oup
educ
atio
nalc
lass
esto
addr
ess
beha
vior
alm
odifi
catio
nsk
ills
and
PA;
self-
mon
itore
din
wee
kly
diar
ies,
feed
back
prov
ided
.
Tota
lfat
(%kc
al):
LF30
%vs
MF
35%
,P�
0.03
.…
Wei
ght
loss
:LF
�2.
9vs
MF
4.8
kgat
18m
o,P�
0.00
1;ES
�0.
33.
…
Sim
kin-
Silv
erm
anet
al,66
2003
,2-
grou
pRC
T/4.
5y
(N�
535)
Wom
en(p
eri-
topo
stm
enop
ausa
l),pr
edom
inan
tlyw
hite
,35
.5%
over
wei
ght,
11%
obes
e.Re
tent
ion
at5
y:95
%.
C:He
alth
educ
atio
npa
mph
let
and
asse
ssm
ent
only
at6,
18,
30,
42,
and
54m
o.Li
fest
yle
inte
rven
tion
(LI):
Phas
e1:
15gr
oup
mee
tings
/20
wks
,lif
esty
lech
ange
s,m
odes
tw
eigh
tlo
ss,
and
PA;
Phas
e2:
6gr
oup
mee
tings
inm
o6–
54;
mai
land
tele
phon
eF/
U.In
divi
dual
nutri
tion
cons
ulta
tion
offe
red
tolo
wer
LDL
chol
este
rol.
Kcal
:C
�24
.8vs
LI�
159.
6kc
al,
P�0.
01;
ES�
0.11
.En
ergy
expe
nditu
re:
C�
113.
3vs
274.
9kc
al,
P�0.
001;
ES�
0.14
.
Wei
ght
loss
:55
%of
LIgr
oup
wer
eat
orbe
low
base
line
wei
ght
com
pare
dw
ith26
%of
Cgr
oup,
P�0.
001.
Mea
nw
eigh
tch
ange
inLI
grou
pw
as0.
1kg
belo
wba
selin
eco
mpa
red
with
mea
nw
eigh
tga
inof
2.4
kgin
Cgr
oup.
…
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 409
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Toob
ert
etal
,67
2005
,2-
grou
pRC
T/6
mo
(N�
279)
Post
men
opau
sal
wom
enw
ithty
pe2
DM,
�90
%w
hite
,BM
I35.
Rete
ntio
n:88
%.
UC:
ongo
ing
diab
etes
care
from
MD
Med
iterr
anea
nLi
fest
yle
Prog
ram
(MLP
):lif
esty
lech
ange
aim
edat
beha
vior
alris
kfa
ctor
saf
fect
ing
CHD
;2.
5-d
retr
eat
follo
wed
byw
eekl
y4-
hm
eetin
gsfo
r6
mo.
Focu
s:di
et,
PA,
stre
ssm
anag
emen
t,so
cial
supp
ort.
Tota
lfat
(g):
UC16
2.1
vsM
LP46
.6g,
P�0.
001;
ES�
20.
Frui
tse
rvin
gs/d
:UC
1.6
vs2.
2,P�
0.00
1Ve
geta
ble
serv
ings
/d:
UC2.
0vs
2.6,
P�0.
001.
PA(M
ETs�
dura
tion�
days
):55
.9UC
vs80
.9M
LP,
P�0.
009.
Wei
ght:
UC93
.4vs
MLP
91.7
kg,
P�0.
004.
…
Wad
den
etal
,72
1998
,4-
grou
pRC
T/1
y(N
�99
)
Wom
en,
mea
nag
e42
y,BM
I36.
Rete
ntio
n:60
.2%
.
Cogn
itive
-beh
avio
ral
trea
tmen
tfo
rw
eigh
tlo
ssde
liver
edin
28w
eekl
yse
ssio
nsfo
llow
edby
10bi
wee
kly
sess
ions
com
bine
dw
ithca
loric
-res
tric
ted
diet
plus
1of
4ex
erci
segr
oups
:(1
)ae
robi
cex
erci
se,
(2)
stre
ngth
trai
ning
�ae
robi
c,(3
)st
reng
thtr
aini
ng,
or(4
)no
exer
cise
beyo
ndlif
esty
leac
tivity
.
……
Wei
ght
loss
:4
grou
ps10
.6–1
1.4
kg,N
SD;a
t1y
35%
–55%
ofw
eigh
tre
gain
ed,
NSD.
…
Wad
den
etal
,28
2005
,4-
grou
pRC
T/1
y(N
�22
4)
Men
&w
omen
,m
ean
age
43.6
y,65
%w
hite
,BM
I37.
8.
Alls
ubje
cts
had
diet
of12
00–1
500
kcal
/dan
dex
erci
se30
min
/dm
ost
days
ofth
ew
eek.
Sibu
tram
ine
Alon
e(S
ibA)
:8
brie
fvi
sits
with
PCP
at1,
3,6,
10,
18,
40,
52w
ks.
Rece
ived
dose
ofsi
butra
min
eat
wk
1;re
ceiv
edpr
int
mat
eria
lsab
out
fitne
ss.
Life
styl
eM
odifi
catio
nAl
one
(LM
A):
Wkl
ygr
oup
mee
tings
from
wks
1–19
,ev
ery
2w
ksfr
omw
ks20
–40,
follo
w-u
pvi
sit
wk
52.
Dai
lyse
lf-m
onito
ring
offo
odin
take
and
PA,
whi
chw
ere
revi
ewed
atw
kly
mee
tings
.Co
mbi
ned
Ther
apy
(CT)
:Sa
me
2tr
eatm
ents
asgr
oups
abov
e.Si
butr
amin
epl
usBr
ief
Ther
apy.
(Sib
�BT
):Si
butr
amin
eas
ingr
oup
1an
dm
etw
ithPC
P10
–15
min
.on
sam
esc
hedu
leas
grou
pm
eetin
gs.
……
Wei
ght
loss
:CT
12.1
�9.
8kg
vsSi
bA5.
0�7.
4kg
vsLM
A6.
7�7.
9kg
vsSi
b�BT
,7.
5�8.
0kg
,P�
0.00
1.Su
bjec
tsin
CTgr
oup
who
self-
mon
itore
dfre
quen
tly:
wei
ght
loss
18.1
�9.
8kg
vs7.
7�7.
5kg
,P�
0.04
.
…
Win
get
al,29
1999
,4-
grou
pRC
T/10
mo
(N�
166)
Wom
enan
dm
en,
age
�42
y,�
90%
whi
te,
BMI
31.2
.Re
tent
ion:
75%
–95%
.
(1)
Recr
uite
dal
one
and
stan
dard
beha
vior
alth
erap
yfo
rw
eigh
tlo
ssS
BT;
(2)
recr
uite
dal
one
and
SBT�
soci
alsu
ppor
t;(3
)re
crui
ted
with
frie
nds
and
SBT;
(4)
recr
uite
dw
ithfr
iend
s&
SBT�
soci
alsu
ppor
t.SB
Tin
clud
esgr
oup
sess
ions
;se
lf-m
onito
ring
calo
ries,
fat,
and
PAin
wee
kly
diar
ies;
and
feed
back
.So
cial
supp
ort:
incl
uded
intr
agro
upac
tiviti
esan
din
terg
roup
com
petit
ion
for
grou
ps2
and
4.
……
Wei
ght
loss
:Re
crui
ted
with
frien
ds�
7.7
kg,
recr
uite
dal
one
�4.
3kg
,P�
0.00
1;ES
�0.
26.
…
Yeh
etal
,6820
03,
2-gr
oup
RCT/
2y
(N�
80)
Wom
en,a
ge30
–60
y,BM
I36.
3an
d37
.9.
Rete
ntio
n:33
%SB
I,35
%CB
.
Offic
e-ba
sed
coun
selin
gw
ithdi
etiti
an(O
BC):
6in
terv
entio
nse
ssio
nsov
er6
mo�
offe
rof
6m
ore.
Skill
sba
sed
inte
rven
tion
(SBI
):tw
o90
-min
dida
ctic
sess
ions
rela
ted
todi
etan
dbe
havi
or;
addi
tiona
lse
ssio
nsfo
rte
chni
cal
skill
build
ing
(sup
erm
arke
t,re
stau
rant
s);
tele
phon
ean
dE-
mai
lac
cess
todi
etiti
anfo
rre
stof
12m
o.
Satu
rate
dfa
t(g
):OB
C�
0.08
vsSB
I�
4.2
gat
24m
o,P�
0.07
.…
Wei
ght
loss
:OB
C�
4.0
vsSB
I�
1.7
at6
mo,
P�0.
05;
1.1
vs�
0.6
at24
mo.
NS.
…
(Con
tinue
d)
410 Circulation July 27, 2010
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Indi
vidu
al-b
ased
inte
rven
tion
deliv
ery
stra
tegi
es
Amm
erm
anet
al,98
2003
,2-
grou
pcl
uste
rra
ndom
ized
trial
,8
rura
lhea
lthde
partm
ents
/12
mo
(N�
468)
71%
fem
ale,
mea
nag
e55
y,80
%w
hite
,75
%HS
educ
atio
n.
Subj
ects
inbo
thgr
oups
wer
ein
form
edof
chol
este
rol
resu
ltsby
lette
r;if
lipid
shi
gh,
they
wer
ein
form
edth
eyne
eded
trea
tmen
t.Sp
ecia
lin
terv
entio
n(S
I):(1
)Pu
blic
heal
thnu
rse
dire
cted
com
pone
ntus
ing
Food
for
Heal
thPr
ogra
mdu
ring
3co
unse
ling
visi
ts;
(2)
refe
rral
toa
loca
lnu
triti
onis
tif
lipid
sre
mai
ned
elev
ated
at3
mo
F/U;
(3)
are
info
rcem
ent
prog
ram
durin
g2n
dha
lfof
inte
rven
tion—
1te
leph
one
call
from
nurs
ean
d2
new
slet
ters
.St
ruct
ured
,in
divi
dual
lyta
ilore
ddi
etar
yco
unse
ling
bynu
rse
faci
litat
edby
adi
etar
yris
kas
sess
men
t,ill
ustr
ated
goal
shee
ts,
and
aSo
uthe
rnst
yle
cook
book
.M
inim
alin
terv
entio
n(M
I):O
ther
than
initi
alle
tter
abou
tch
oles
tero
lre
sults
,ot
her
inte
rven
tion
activ
ities
not
desc
ribed
.
Diet
ary
Risk
Asse
ssm
ent
Scor
e2.
1un
itsbe
tter
inth
eSI
vsM
I,P�
0.00
5.
…NS
Din
wei
ght
loss
.Re
duct
ion
into
talc
hole
ster
olsi
mila
rin
both
grou
ps:
18.4
mg/
dLin
SIvs
15.6
mg/
dLin
MI,
P�0.
06.
Burk
eet
al,30
2005
,2-
grou
pRC
T/14
wks
(N�
65)
�60
%m
ale,
94%
whi
te,
BMI
38–4
5.Re
tent
ion:
98%
.
UC:
Usua
lclin
ical
care
.I:
Tele
phon
e-de
liver
ed,
self-
effic
acy–
base
dco
unse
ling
toim
prov
ead
here
nce
toa
chol
este
rol-
low
erin
gdi
et,
6se
ssio
nsov
er12
wks
,in
clud
edgo
alse
tting
,se
lf-m
onito
ring
with
feed
back
,se
lf-ef
ficac
yen
hanc
emen
t.
Fat
chan
gesc
ore:
UC2.
3vs
I�
10.4
gP�
0.03
5;ES
�0.
29.
Satu
rate
dfa
tch
ange
scor
e:UC
0.18
vsI�
23g,
P�0.
045;
ES�
0.28
.
……
LDL-
Cch
ange
scor
e:UC
0.25
vsI0
.42
mg/
dL,
P�0.
013;
ES�
0.30
.
Delic
hats
ios
etal
,130
2001
,2-
grou
pcl
uste
rra
ndom
ized
trial
/3m
o(N
�50
4)
70%
fem
ale,
91%
whi
te,
mea
nag
e54
y.
C:Us
ualP
CPpr
actic
eI:
3co
mpo
nent
s—pe
rson
aliz
eddi
etre
com
men
datio
nsan
dst
age-
mat
ched
diet
-rel
ated
educ
atio
nal
book
lets
bym
ail,
prov
ider
endo
rsem
ent
ofth
ere
com
men
datio
ns,
and
2m
otiv
atio
nal
inte
rvie
wco
unse
ling
sess
ions
byte
leph
one.
Coun
selin
gen
cour
aged
goal
-set
ting
and
stag
eof
chan
gem
essa
ges.
F/V:
Chan
gein
F/V
inta
kein
Igro
upw
as0.
6(C
I,0.
3–0.
8)se
rvin
gs/d
high
erth
anco
ntro
lgro
up.
……
…
Ellio
tet
al,71
2007
,3-
grou
pcl
uste
rra
ndom
ized
trial
/12
mo
(N�
599)
97%
mal
efir
efig
hter
s,m
ean
age
41y,
91%
whi
te,
inco
me
�$5
000
0.
Both
inte
rven
tion
grou
psre
ceiv
eda
Heal
than
dFi
tnes
sgu
ide.
Team
cent
ered
:W
ork
grou
psw
ithde
sign
ated
lead
erm
etfo
r11
45-m
inse
ssio
nsan
dfo
llow
edsc
ripte
dle
sson
plan
son
nutr
ition
,PA
,en
ergy
bala
nce,
stre
ss,
slee
p,an
ddi
etar
ysu
pple
men
ts.
Mem
bers
rece
ived
base
line
PA,
diet
ary,
and
lab
asse
ssm
ent
resu
ltsfo
llow
edby
goal
setti
ng.
Mot
ivat
iona
lIn
terv
iew
ing
(MI):
Part
icip
ants
rand
omly
assi
gned
to1
of6
MI
coun
selo
rs;
4m
eetin
gsw
ithM
Ico
unse
lor
with
poss
ibili
tyof
5ho
urs
ofad
ditio
nal
inpe
rson
orte
leph
one
cont
act.
Cont
rol:
Rece
ived
only
test
resu
ltsw
ithex
plan
atio
nof
norm
alva
lues
;fr
eeto
use
own
initi
ativ
eto
alte
rlif
esty
le.
F/V:
Both
Team
and
MIh
adin
crea
sed
F/V
inta
ke(P
�0.
05).
PA:
Team
and
MIi
ncre
ased
no.
ofsi
t-up
sin
1m
in,
P�0.
05.
Wei
ght:
Both
Team
and
MI
gain
edw
eigh
t,bu
tle
ssga
inth
anUC
,P�
0.05
.
…
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 411
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Keys
erlin
get
al,22
7
2-gr
oup
RCT,
rand
omiz
atio
nof
clin
icia
n-pa
tient
grou
ps/1
y(N
�37
2)
42ph
ysic
ians
,�
66%
patie
ntpa
rtici
pant
sw
ithhi
ghch
oles
tero
lw
ere
fem
ale,
40%
blac
k,11
%Na
tive
Amer
ican
,M
ean
age
55.9
y,10
.6m
ean
yed
ucat
ion.
I:3
com
pone
nts—
(1)
clin
icia
n-di
rect
eddi
etar
yco
mpo
nent
;(2
)re
ferr
alto
alo
cald
ietit
ian
ifLD
L-C
rem
aine
del
evat
edat
4m
ofo
llow
-up
with
�2
risk
fact
ors
orCH
D;(3
)a
prom
ptfo
rth
ecl
inic
ian
toco
nsid
erdr
ugtre
atm
ent
base
don
LDL-
Cat
7m
ofo
llow
-up.
UC:
Phys
icia
nsw
ere
advi
sed
tom
anag
eth
eir
subj
ects
hype
rcho
lest
erol
emia
acco
rdin
gto
thei
rus
ualp
ract
ices
.
……
…To
talc
hole
ster
ol:A
t4-m
ofo
llow
-up,
tota
lcho
lest
erol
decr
ease
d0.
33m
mol
/Lin
the
Igro
upvs
0.21
mm
ol/L
inth
eC
grou
p(9
0%CI
,�
0.02
–0.
24m
mol
/L).
The
mea
nre
duct
ion
at1-
yfo
llow
-up
was
0.09
grea
ter
inth
eIg
roup
(90%
CI,
�0.
01–
0.19
mm
ol/L
).Ch
ange
sin
LDL-
Cw
ere
sim
ilar.
Mar
cus
etal
,69
2007
,3-
grou
pRC
T/12
mo
(N�
239)
82%
fem
ale,
90.3
%w
hite
,m
ean
age
44.5
y,m
ean
BMI
28.5
,60
%w
ithho
useh
old
inco
me
�$5
000
0.
C:He
alth
educ
atio
nm
ater
ialm
aile
don
sam
esc
hedu
leas
prin
tan
dte
leph
one;
subj
ects
com
plet
edPA
log
each
mon
th.
Tele
phon
e(T
):Su
bjec
tsre
ceiv
edPA
inte
rven
tion
mat
eria
lsth
roug
hte
leph
one
cont
act
with
ahe
alth
educ
ator
.Ed
ucat
orin
corp
orat
edin
divi
dual
lyta
ilore
dfe
edba
ckge
nera
ted
byan
expe
rtco
mpu
ter
syst
eman
dpr
ovid
edco
unse
ling
usin
ga
mot
ivat
ion
stag
ed-m
atch
edm
anua
l.M
ean
leng
thof
calls
was
13m
in;
90%
ofca
llsw
ere
com
plet
ed,
14co
ntac
tsov
erth
eco
urse
of12
mo.
Com
plet
edPA
log
each
mon
th.
Prin
t(P
):Su
bjec
tsre
ceiv
edin
divi
dual
lyta
ilore
dpr
inte
dre
ports
ofPA
,fe
edba
ckge
nera
ted
byex
pert
com
pute
rsy
stem
,al
ong
with
man
uals
mat
ched
toth
eir
stag
eof
read
ines
san
dtip
shee
ts,
14co
ntac
ts.
Com
plet
edPA
log
each
mon
th.
…PA
:At6
mo,
subj
ects
inT
grou
p(1
23.3
�97
.6)a
ndP
grou
p(1
29.5
�15
6.5)
repo
rted
larg
erin
crea
sein
min
ofPA
/wk
than
subj
ects
inC
grou
p(M
�77
.7�
101.
89),
P�0.
02.
At12
mo,
Pgr
oup
repo
rted
grea
term
oder
ate-
inte
nsity
PAco
mpa
red
with
Cgr
oup,
NSD
betw
een
Tan
dP
grou
ps.
……
Gree
net
al,31
2002
,2-
grou
pRC
T/6
mo
(N�
316)
52.5
%fe
mal
e,91
.5%
whi
te,
med
ian
age
44.5
y.
UC:
Note
leph
one
calls
.I:
320
–30
min
tele
phon
eca
llsm
onth
lyfo
r3
mo
from
beha
vior
alhe
alth
spec
ialis
tsw
hopr
ovid
edm
otiv
atio
nalc
ouns
elin
gin
acco
rdan
cew
ithst
ages
-of-
chan
gem
odel
,go
alse
tting
,as
sist
ance
with
prob
lem
-sol
ving
barr
iers
,an
did
entif
yre
sour
ces
for
supp
ort.
…PA
:Hi
gher
PAle
velp
erPA
CEsc
ore
for
I5.3
7vs
4.98
inUC
,P�
0.05
.
……
Orni
shet
al,22
2
1998
,2-
grou
pra
ndom
ized
invi
tatio
nald
esig
n/5
y(N
�35
)
91%
mal
ew
ithm
oder
ate
tose
vere
CHD,
Mea
nag
e59
.6y,
mea
n15
yof
educ
atio
n.
I:In
tens
ive
lifes
tyle
chan
ge,
10%
fat,
vege
taria
ndi
et,
aero
bic
exer
cise
,st
ress
man
agem
ent,
smok
ing
cess
atio
n,gr
oup
psyc
hoso
cial
supp
ort
for
5ye
ars.
C:Fo
llow
advi
ceof
phys
icia
nre
gard
ing
lifes
tyle
chan
ges.
Fat
inta
ke:
Igro
upfa
tin
take
decr
ease
d30
%to
8.5%
,P�
0.00
1;di
etar
ych
oles
tero
lde
crea
sed
211
to18
.6m
g/d,
P�0.
002
Cgr
oup
decr
ease
dfa
tin
take
30%
to25
%.
…W
eigh
t:Ig
roup
12.8
lblo
ssvs
noch
ange
inC
grou
p,P�
0.00
1.
LDL-
C:Ig
roup
decr
ease
s20
%vs
19.3
%in
Cgr
oup,
NSD
betw
een
grou
ps.
Arte
rials
teno
sis
decr
ease
dfro
mba
selin
ein
Igro
up,
P�0.
001
betw
een
grou
ps.
Ocke
neet
al,95
1999
,3-
grou
pRC
T/1
y
927
prim
ary
care
subj
ects
,45
prim
ary
care
inte
rnis
ts.
66%
fem
ale,
�90
%w
hite
,BM
I29.
Rete
ntio
nno
tre
porte
d.
UC:
Usua
lclin
ical
care
inpr
imar
yca
rese
tting
.Ph
ysic
ian
nutri
tion
coun
selin
gtra
inin
g:2
sess
ions
,a
2.5-
hsm
allg
roup
sess
ion
and
a30
-min
indi
vidu
aliz
edtu
toria
l;in
clud
eddi
dact
icin
stru
ctio
n,vi
deot
ape
obse
rvat
ion,
and
role
-pla
ying
.Ph
ysic
ian
nutri
tion
coun
selin
gtra
inin
g�of
fice-
supp
ort
prog
ram
:As
abov
e�of
fice-
supp
ort
prog
ram
desi
gned
toas
sist
MD
inca
rryi
ngou
tco
unse
ling
sequ
ence
,eg
,pa
tient
com
plet
edDi
etar
yRi
skAs
sess
men
tin
wai
ting
room
,lip
idre
sults
flagg
ed.
Note
:co
unse
ling
took
8.2
min
,5.
5m
inm
ore
than
cont
rolc
ondi
tion.
Fat
%kc
al:
Grou
p1
vs2
vs3
�0.
7%vs
�1.
0%vs
�2.
3%,
P�0.
11.
Satu
rate
dfa
t(%
kcal
):0.
0vs
�0.
4vs
�1.
1%,
P�0.
01;
ES�
0.10
.
…W
eigh
tlo
ss:
Grou
p1
vs2
vs3
0.0
vs�
1.0
vs�
2.3
kg,
P�0.
001.
LDL-
C:�
0.01
vs0.
02vs
�0.
11m
mol
/L,
P�0.
10.
Tota
lcho
lest
erol
:HD
Lra
tio:
0.1
vs0.
1vs
�0.
1m
g/dL
,P�
0.00
4. (Con
tinue
d)
412 Circulation July 27, 2010
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Pint
oet
al,12
520
05,
2gr
oup/
6m
o(N
�10
0)
85%
whi
te,
63%
fem
ale
BMI2
9.Re
tent
ion:
EA46
,BA
44.
Brie
fad
vice
(BA)
:Br
ief
advi
ceto
exer
cise
bya
clin
icia
nal
one.
Exte
nded
advi
ce(E
A):
Brie
fad
vice
toex
erci
sefro
ma
clin
icia
nsu
pple
men
ted
byte
leph
one-
base
dco
unse
ling
byhe
alth
educ
ator
s,co
unse
ling
tailo
red
tosu
bjec
t’sre
adin
ess
toin
crea
sePA
leve
lsas
wel
las
thei
rco
nvic
tion
and
conf
iden
ce;
used
mot
ivat
iona
lint
ervi
ewin
gte
chni
ques
.
…En
ergy
expe
nditu
re:
BA�
0.83
vsEA
�3.
8kc
al/w
k3
mo,
P�0.
03;
ES�
0.23
;6
mo,
P�0.
05,
ES�
0.20
.
……
Rich
ards
etal
,104
2006
,2-
grou
pRC
T/4
mo
(N�
437)
100%
colle
gest
uden
ts;
mea
nag
e20
.4y,
75%
wom
en,
96%
whi
te.
I:Su
bjec
tsre
ceiv
eda
pers
onal
ized
lette
rto
stag
eof
chan
ge,
ase
ries
of4
stag
e-ba
sed
new
slet
ters
spec
ific
toth
eir
stag
eof
chan
geat
base
line,
1m
otiv
atio
nali
nter
view
ing
sess
ion,
refe
rral
toa
nutri
tion
Web
site
,an
da
min
imum
of2
E-m
ailc
onta
cts
over
a4-
mo
perio
d.C:
Subj
ects
com
plet
edba
selin
ean
dfo
llow
ing
surv
eys
with
noad
ditio
nal
cont
act
from
stud
ype
rson
nel.
F/V:
Cons
umpt
ion
incr
ease
dby
1se
rvin
g.d
inIg
roup
asm
easu
red
bya
26-it
emFF
Qan
da
1-ite
mFF
Qvs
0.4
serv
ings
/din
Cgr
oup
per
the
1-ite
mFF
Qan
dno
chan
gepe
rth
e26
-item
FFQ.
……
…
Stev
ens
etal
,32
2003
,2-
grou
pRC
T/12
mo
(N�
616)
Wom
en,
mea
nag
e54
.4y,
91%
whi
te,
BMI
30.2
�7.
1.Re
tent
ion
I:89
%,
Con:
85%
.
C:Fo
cuse
don
brea
stse
lf-ex
amin
atio
n,in
divi
dual
sess
ion�
vide
otap
e,an
d2
F/U
tele
phon
eca
lls.
I:Tw
o45
-min
diet
coun
selin
gse
ssio
ns�
2br
ief
F/U
tele
phon
eco
ntac
ts,
with
goal
setti
ng,
feed
back
,pr
oble
m-s
olvi
ng,
and
mot
ivat
iona
lint
ervi
ewin
gst
rate
gies
;de
liver
edby
mas
ter’s
prep
ared
heal
thco
unse
lors
.
Fat
(%):
C38
.6%
vs34
.9%
,P�
0.00
1F/
V(s
ervi
ngs)
:C
3.4
vs4.
3,P�
0.00
1;ES
�0.
13.
……
…
Com
pute
r/In
tern
et-
base
din
terv
entio
nde
liver
yst
rate
gies
Ande
rson
etal
,33
2001
,2-
grou
pRC
T/6
mo
(N�
277)
96%
fem
ale,
96%
whi
te,
med
ian
inco
me
�$3
500
0.
C:No
expo
sure
tosu
perm
arke
tki
osks
.I:
Subj
ects
used
supe
rmar
ket
kios
k-ba
sed
self-
adm
inis
tere
d,co
mpu
ter-
base
dSC
Tin
terv
entio
n;pr
ovid
edpe
rson
aliz
edin
fo,
beha
vior
alst
rate
gies
,in
cent
ives
for
chan
ge,
and
feed
back
onpe
rson
algo
als.
Prog
ram
guid
ein
crea
sefib
er,
F/V,
and
redu
ced
fat
info
odpu
rcha
ses
thro
ugh
15w
eekl
yse
gmen
ts;
offe
red
food
coup
ons
of$8
–$12
/wk.
Fat,
fiber
,F/
V:Ig
roup
mor
elik
ely
than
Cgr
oup
toat
tain
goal
sfo
rfa
t,fib
er,
F/V.
……
…
Delic
hats
ios
etal
,17
2001
,2-
grou
pRC
T/6
mo
(N�
298)
72%
fem
ale,
45%
whi
te,
45%
blac
k,m
ean
age
45.9
5y,
BMI2
8.7,
85%
empl
oyed
.
C:Us
edan
inte
ract
ive,
com
pute
r-ba
sed
syst
emto
serv
eas
anat
-hom
em
onito
r,ed
ucat
or,
and
coun
selo
rre
gard
ing
diet
.Su
bjec
tsca
lled
syst
em1/
wk
for
6m
o;re
ceiv
edre
min
der
call
ifsu
bjec
tdi
dno
tca
llsy
stem
in2
wks
.I:
Used
sam
esy
stem
asC
exce
ptco
nver
satio
nfo
cuse
don
PA.
F/V:
Igro
upra
ised
no.
ofse
rvin
gsof
fruit
com
pare
dw
ithC
grou
p(C
I,4–
1.7)
.No
diffe
renc
esfo
rve
geta
bles
.Di
etar
yfib
erra
ised
by4.
0g/
dco
mpa
red
with
Cgr
oup
(CI,
1–7.
8).
……
…
Gold
etal
,122
2007
,2-
grou
pRC
T/12
mo
(N�
124)
98%
wom
en,
98%
whi
te,
age
47y,
BMI3
2.Re
tent
ion:
65%
inVT
rim,
77%
ineD
iets
.
VTrim
:Ac
cess
toth
erap
ist-
led
stru
ctur
edbe
havi
oral
wei
ght
loss
prog
ram
deliv
ered
onlin
e.eD
iets
.com
:Ac
cess
tose
lf-he
lpco
mm
erci
alw
eigh
tlo
sspr
ogra
mW
ebsi
te.
……
Wei
ght
loss
:VT
rim�
8.3
kgvs
eDie
t�
4.1
kgat
6m
os,
P�0.
004,
ES�
0.21
;at
12m
o,�
7.8
vs�
3.4,
P�0.
002,
ES�
0.16
.
…
Mar
cus
etal
,108
2007
,3-
grou
pRC
T/12
mo
(N�
249)
83.7
%fe
mal
e,m
ean
age�
44.5
�9.
3y,
BMI2
9.4.
Rete
ntio
n:87
.1%
.
Tailo
red
Inte
rnet
:M
otiv
atio
nally
tailo
red
Inte
rnet
mat
eria
ls.
Tailo
red
prin
t:M
otiv
atio
nally
tailo
red
prin
tm
ater
ials
.Re
sear
cher
-sel
ecte
dW
ebsi
tes:
avai
labl
eto
the
publ
ic.
…PA
(min
):NS
Dam
ong
3gr
oups
;w
ithin
grou
pin
crea
seat
6m
o(5
.2%
),12
mo
(5.9
%).
……
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 413
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Napo
litan
oet
al,34
2003
,2-
grou
pRC
T(N
�65
)
86%
wom
en,
mea
nag
e42
.8y,
91%
whi
te,
55%
�$5
000
0in
com
e/y,
BMI
26.4
.88
%re
tent
ion
3m
o.
C:Re
ceiv
edIa
fter
3-m
ow
ait.
I:Re
ceiv
edac
cess
toW
ebsi
tefo
r3
mo
alon
gw
ithw
eekl
yE-
mai
ltip
shee
ts.
Web
site
base
don
SCT,
targ
eted
stag
esof
mot
ivat
iona
lrea
dine
ss,
and
prov
ided
PAin
form
atio
nto
help
reac
hgo
al(e
g,us
eof
soci
alsu
ppor
t,re
war
ds,
plan
ning
inac
tivity
).
…PA
:At
1m
o,su
bjec
tsin
Igr
oup
had
high
erle
vels
ofm
oder
ate
min
/wk
and
wal
king
min
/wk
vsC
grou
p(P
�0.
05,
�0.
001,
resp
ectiv
ely)
;At
3m
o,on
lyw
alki
ngm
inw
ere
high
erco
mpa
red
with
Cgr
oup
(P�
0.05
).
……
Mic
coet
al,35
2007
,2-
grou
pRC
T/12
mo
(N�
123)
83%
fem
ale,
96%
whi
te,
mea
nag
e46
.8y,
BMI3
1.7,
74%
with
colle
gede
gree
s.
Inte
rnet
:12
-mo
SBT
wei
ght
loss
prog
ram
taug
htth
roug
hse
ries
ofon
line
less
ons.
Subj
ects
met
wee
kly
inon
line
chat
room
s.Ho
mew
ork
assi
gnm
ents
subm
itted
elec
troni
cally
befo
rem
eetin
g.Pr
escr
ibed
diet
of12
00–2
100
cal/d
.Em
phas
ized
diet
abun
dant
inF/
Van
dw
hole
grai
nsan
dm
oder
ate
infa
t,su
gar,
and
salt;
emph
asiz
edex
erci
sing
5–7
days
/wk.
Onlin
em
eetin
gsad
dres
sed
self-
mon
itorin
gan
dse
tting
calo
riean
dPA
goal
s;jo
urna
lspr
ovid
edba
sis
for
feed
back
.In
tern
etpl
usin
-per
son:
Subj
ects
rece
ived
sam
eIn
tern
etpr
ogra
mpl
usm
eton
cea
mon
thas
agr
oup
inpe
rson
.In
-per
son
mee
tings
took
the
plac
eof
onlin
ech
atse
ssio
ns,
led
bydi
ffere
ntfa
cilit
ator
(die
titia
n)th
anon
line
chat
s.
……
Wei
ght
loss
:No
sign
ifica
ntgr
oup�
time
diffe
renc
ein
wei
ght
loss
at6
or12
mo.
Com
plet
ers
lost
mea
n7.
5�6.
4kg
at6
mo
and
6.6�
6.6
kgov
er12
mo.
…
Pint
oet
al,13
220
02,
2-gr
oup
RCT/
6m
o(N
�29
8)
72%
fem
ale,
45%
whi
te,
mea
nag
e45
.9y,
BMI
28–3
0.Re
tent
ion:
TLC-
PA75
%,
TLC-
Eat
89%
.
Tele
phon
e-lin
ked
com
mun
icat
ion
(TLC
)-Ea
t:Pr
omot
edhe
alth
yea
ting,
com
paris
ongr
oup.
TLC-
PA:
Prom
oted
regu
lar
mod
erat
ein
tens
ity(M
I)PA
;TL
Cco
mpu
ter
tech
nolo
gy,
and
digi
tized
hum
ansp
eech
toco
nver
seth
roug
hto
tally
auto
mat
edte
leph
one
conv
ersa
tions
.
NSD
Ener
gyex
pend
iture
:TL
C-E
2.0
vsTL
C-PA
2.3
kcal
/kg/
dat
3m
o,P�
0.02
;ES
�0.
23;
NSD
at6
mo,
ES�
0.02
.
……
Tate
etal
,3620
03,
2-gr
oup
RCT/
1y
(N�
92)
90%
fem
ale,
89%
whi
te,
BMI3
3.Re
tent
ion:
85%
.
Alls
ubje
cts
atte
nded
grou
pse
ssio
n:or
ient
edto
Inte
rnet
;in
stru
cted
onca
lorie
,fa
tre
stric
tion,
PAgo
als;
how
tose
lf-m
onito
r.Ba
sic
Inte
rnet
(BI):
Web
site
tuto
rialo
nw
eigh
tlo
ss,
wee
kly
tipan
dlin
k,di
rect
ory
ofIn
tern
etre
sour
ces,
wee
kly
E-m
ailr
emin
der
tosu
bmit
wei
ght
and
give
nw
eigh
tlo
ssin
fo.
Inte
rnet
wei
ght
loss
prog
ram
�be
havi
oral
E-co
unse
ling
(I�Be
):E-
mai
lco
mm
unic
atio
nw
ithco
unse
lor,
subm
itca
lorie
/fat
inta
ke,
PAon
Web
-bas
eddi
ary
daily
for
1m
o,da
ilyor
wee
kly
for
11m
o;w
eekl
yco
unse
lor
E-m
ailg
ave
feed
back
.
Fat
(%kc
al):
�1%
inBI
grou
pvs
�4%
inI�
Be,
P�0.
06.
Incr
ease
sin
ener
gyex
pend
iture
:�
63in
BIvs
�34
2kc
alin
I�Be
,P�
0.26
.
Wei
ght
loss
:BI
�2.
0kg
vs�
4.4
kgin
I�Be
,P�
0.04
;ES
�0.
21.
…
Tate
etal
,5720
06,
3-gr
oup
RCT/
6m
o(N
�19
2)
�80
%,
�90
%w
hite
,BM
I33.
Rete
ntio
n:82
%at
3m
o,80
%at
6m
o.
Alls
ubje
cts
rece
ived
1gr
oup
sess
ion,
mea
lrep
lace
men
tco
upon
s,ac
cess
toan
inte
ract
ive
Web
site
.No
coun
selin
g(N
C)Co
mpu
ter-
auto
mat
edfe
edba
ck(A
F):
Acce
ssto
elec
troni
cdi
ary
for
self-
mon
itorin
gfo
ods,
PA,
wei
ght;
mes
sage
boar
d;w
eekl
y:E-
mai
lre
min
der
tose
lf-m
onito
r,be
havi
oral
less
on,
and
feed
back
from
prep
rogr
amm
edco
mpu
ter.
Hum
anE-
mai
lCou
nsel
ing
(HC)
:AF
exce
ptfe
edba
ckde
liver
edvi
aE-
mai
lfro
mhu
man
wei
ght
loss
coun
selo
r.
Kcal
:NS
DFa
tin
take
(%/d
):NC
37.2
vsAF
34.0
vsHC
33.1
%/d
,P�
0.00
4.
NSD
Wei
ght
loss
:NC
�2.
6vs
AF�
4.9
vsHC
�7.
2kg
,P�
0.00
1;ES
�0.
29.
…
(Con
tinue
d)
414 Circulation July 27, 2010
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Wyl
ie-R
oset
tet
al,37
2001
,3-
grou
pRC
T/12
mo
(N�
588
from
HMO)
82%
fem
ale,
mea
nag
e52
y,83
%w
hite
,84%
�1
yof
colle
ge,m
ean
BMI3
5.6.
Rete
ntio
n:81
%.
3in
crem
enta
llev
els
ofw
eigh
tlo
ssin
terv
entio
nin
tens
ity:
(1)
Wor
kboo
kal
one
(W);
(2)
addi
tion
ofco
mpu
teriz
edta
ilorin
gus
ing
on-s
iteco
mpu
ter
scre
ens
with
touc
hscr
een
mon
itors
(W�
C);
(3)
addi
tion
ofbo
thco
mpu
ters
and
staf
fco
nsul
tatio
n(ie
,6
clos
ed-g
roup
sess
ions
and
upto
18te
leph
one
orin
-per
son
cons
ulta
tions
).(W
�C�
S).
All3
inte
rven
tions
used
cogn
itive
beha
vior
alap
proa
chfo
rta
ilorin
ggo
als
and
prin
cipl
esof
trans
theo
retic
alm
odel
ofbe
havi
oral
chan
ge.
Mea
nen
ergy
inta
kean
dpe
rcen
ten
ergy
from
fat
decr
ease
dfro
mba
selin
ein
all3
grou
ps(P
�0.
01).
NSD
inm
ean
nutri
ent
inta
keby
grou
p.
Allg
roup
sre
porte
da
mea
nin
crea
sein
wal
king
time
and
num
ber
ofbl
ocks
wal
ked
each
day
(P�
0.01
).NS
Dby
inte
rven
tion
grou
p.
Allg
roup
slo
stw
eigh
t.W
�C�
Slo
stsi
gnifi
cant
lym
ore
wei
ght
than
Won
ly,
P�0.
02.
W�
Cdi
dno
tlo
sew
assi
gnifi
cant
lygr
eate
rw
eigh
tth
anW
only
.
…
Mul
ticom
pone
ntin
terv
entio
nde
liver
yst
rate
gies
Care
lset
al,15
2007
,RC
T/6
mo
(N�
55)
87%
wom
en,o
bese
adul
ts,9
4%w
hite
,BM
Inot
prov
ided
.Re
tent
ion:7
9–81
%.
Beha
vior
wei
ght
loss
prog
ram
(BW
LP):
20se
ssio
nsba
sed
onLE
ARN
prog
ram
.BW
LP�
step
ped
care
(SC)
:In
divi
dual
sin
the
BWLP
�SC
grou
pw
hodi
dno
tm
eet
wei
ght
loss
goal
rece
ived
mot
ivat
iona
lint
ervi
ewin
gst
rate
gies
(MI).
Tota
lcal
orie
s:BW
LP�
380
kcal
vsBW
LP�
SC�
358
kcal
,ES
�0.
11(P
valu
esno
tre
porte
d).
VO2
BWLP
�2.
3vs
BWLP
�SC
�1.
7,ES
�0.
12.
Wei
ght
loss
:BW
LP�
2.1
vsBW
LP�
SC�
4.5,
ES�
0.84
.…
Cook
etal
,221
2007
,lo
ng-t
erm
follo
w-u
p10
–15
yaf
ter
TOHP
Iand
TOHP
IItri
als
(N�
744
inTO
HPI;
N�23
82TO
PHII)
Acro
ssbo
thtri
als:
68.5
%m
en,
�78
%w
hite
,�
17%
blac
k,m
ean
age
43.3
y,m
ean
BMI�
29.
TOHP
trial
:Te
sted
nonp
harm
acol
ogic
alin
terv
entio
ns(ie
,w
eigh
tlo
ss,
Na�
redu
ctio
n,st
ress
man
agem
ent,
and
nutri
tiona
lsup
plem
ents
)in
redu
cing
BPin
subj
ects
with
high
norm
alBP
.Of
2182
TOHP
Isub
ject
s,32
7w
ere
rand
omiz
edto
Na�
redu
ctio
nan
d41
7w
ere
assi
gned
toUC
.In
divi
dual
and
wee
kly
grou
pse
ssio
nsof
fere
dfo
r3
mo;
lifes
tyle
inte
rven
tions
wer
eof
fere
dfo
r18
mo.
Com
pare
dw
ithUC
,Na
�an
dBP
sign
ifica
ntly
decr
ease
d.TO
PHII:
Test
edth
eef
fect
sof
wei
ght
loss
and
Na�
onin
cide
nthy
perte
nsio
nan
dBP
over
3–4
year
s.2�
2fa
ctor
iald
esig
n.Th
eNa
�re
duct
ion
only
grou
pha
dsi
gnifi
cant
lylo
wer
Na�
excr
etio
nw
ithco
rres
pond
ing
sign
ifica
ntde
crea
sein
SBP.
……
…CV
D:Ri
skof
aCV
Dev
ent
(MI,
stro
ke,
CVre
vasc
ular
izat
ion
orCV
deat
h)w
as25
%lo
wer
amon
gth
ose
inin
terv
entio
ngr
oup,
adju
sted
for
trial
,cl
inic
,ag
e,se
x,an
dra
ce;
risk
was
30%
low
eraf
ter
furth
erad
just
men
tfo
rba
selin
eNa
�ex
cret
ion
and
wei
ght.
Diab
etes
Prev
entio
nPr
ogra
mRe
sear
chGr
oup,
38,2
2820
04,
3-gr
oup
RCT/
aver
age
2.8
y(N
�32
34)
ILIg
roup
was
68%
fem
ale,
46.3
%m
inor
ity,
BMI3
4.Re
tent
ion:
92.5
%
Stan
dard
:st
anda
rdlif
esty
lepl
aceb
ogr
oup
Met
form
in:
850
mg
twic
eda
ily.
Inte
nsiv
eLi
fest
yle
Inte
rven
tion
(ILI):
Mai
ngo
al:
lose
7%of
base
line
wei
ght
and
achi
eve
150
min
/wk
ofPA
;in
divi
dual
case
man
ager
for
full
time
ofst
udy—
16se
ssio
nsin
core
curr
icul
umco
vere
dba
sic
skill
sre
late
dto
nutri
tion,
exer
cise
,an
dbe
havi
orch
ange
.Di
et�
25%
fat�
calo
riere
stric
tion.
Self-
mon
itore
dm
inof
PAan
dfa
tg
cons
umed
ever
yda
ydu
ring
core
curr
icul
um,
then
1w
k/m
ore
mai
nder
oftri
al.
Note
:In
cide
nce
ofdi
abet
esre
duce
dsi
gnifi
cant
lygr
eate
rin
the
ILIg
roup
than
inth
est
anda
rdan
dm
etfo
rmin
grou
ps.
For
ILL
grou
p:Kc
al/d
:�
452
at1
yTo
talf
at/d
(g):
�30
.3at
1y
%of
calf
rom
fat:
�6.
6%at
1y.
PA(M
ETS)
:�
6.6
at1
y,�
4.3
MET
Sat
3y.
Wei
ght
loss
:�
4.2
kgin
ILI
grou
pvs
0.8
kgin
stan
dard
grou
p,P�
0.05
at12
mo.
InIL
L,�
4.1
kgat
3y.
…
Glas
gow
etal
,39
1997
,2-
grou
pRC
T/12
mo
(N�
206)
Adul
tsw
ithDM
,�60
%fe
male
,mea
nag
e62
y,77
%ov
erw
eight
orob
ese,
race
not
repo
rted.
Rete
ntion
:In
terv
entio
n:83
.3%
;UC
:84.
7%.
UC:
Quar
terly
med
ical
care
and
F/U
ofris
kfa
ctor
s�to
uch-
scre
enco
mpu
ter
asse
ssm
ent
inm
edic
alof
fice.
Brie
fIn
terv
entio
n(B
I):Si
ngle
sess
ion,
touc
h-sc
reen
com
pute
r–as
sist
edas
sess
men
t,im
med
iate
feed
back
onke
yba
rrie
rsto
diet
ary
self-
man
agem
ent,
goal
setti
ng,
and
prob
lem
-sol
ving
coun
selin
g;ad
ditio
nal
vide
oin
terv
entio
nba
sed
onse
lf-ef
ficac
ysc
ore
(�85
vs�
85).
Tele
phon
eca
lls/v
ideo
tape
s1
and
3w
ks;
inte
rven
tion
repe
ated
at3
mo;
tele
phon
eca
llat
6m
o,DM
book
at12
mo.
Kcal
:UC
1659
vsBI
1547
kcal
,P�
0.05
;ES
�0.
14Fa
t(%
):UC
32.0
%vs
30.5
%,
P�0.
023;
ES�
0.16
.
…BM
I:NS
D.Ch
oles
tero
l:UC
226
vsBI
208,
P�0.
002
HbA 1
c,NS
D.
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 415
Tabl
e2.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Glas
gow
,8020
00,
2�2
Fact
oria
lRC
T/6
mo
(N�
320)
Adul
tsw
ithty
pe2
DM,m
ean
age
59y,
BMIn
otre
porte
d.Re
tent
ion:
84%
–94
%fo
r4
grou
ps.
Subj
ects
rece
ived
Basi
cIn
terv
entio
n(B
I):he
alth
coun
selo
rm
eetin
g,di
etar
ygo
als
set
with
aid
ofto
uch-
scre
enco
mpu
ter,
feed
back
ondi
etar
ypa
ttern
.Ta
ilore
ddi
etar
yfa
tre
duct
ion
goal
.4
grou
ps:
(1)
BI;
(2)
BI�
TF(3
–4
tele
phon
efo
llow
-up
calls
/6m
ofo
ron
goin
gsu
ppor
t,re
info
rcem
ent,
and
prob
lem
-sol
ving
);(3
)BI
�Co
mm
unity
Reso
urce
s(C
R)En
hanc
emen
t;(4
)Co
mbi
ned
Cond
ition
s.CR
Enha
ncem
ent:
bind
erof
reso
urce
s,4
new
slet
ters
,go
alse
tting
,an
dFF
Qco
mpl
eted
/giv
enta
ilore
dfe
edba
ck.
Fat:
NSD;
ES�
0.19
.Fa
t/fib
erbe
havi
ors:
TFgr
oups
bette
r,P�
0.01
7.
…NS
DCh
oles
tero
l:CR
�ph
ase
P�0.
010
HbA 1
c,NS
D
How
ard
etal
,58
2006
,W
HI:
Diet
ary
Mod
ifica
tion
Tria
l2-
grou
pRC
T/7.
5y
(N�
4883
5)
Post
men
opau
sal
wom
en,
81%
whi
te,
BMI2
9.Re
tent
ion:
96%
.
C:Us
uald
iet,
rece
ived
diet
-rel
ated
educ
atio
nm
ater
ials
(Die
tary
Guid
elin
esfo
rAm
eric
ans)
I:Gr
oup
(18
sess
ions
infir
stye
ar,
4/y
afte
rwar
d)an
din
divi
dual
sess
ions
topr
omot
ede
crea
sein
fat
inta
ke,
incr
ease
inF/
Van
dgr
ain
inta
ke;
mai
ntai
nus
uale
nerg
yin
take
(no
wei
ght
loss
orca
lorie
rest
rictio
ngo
als)
.Th
ree
indi
vidu
alse
ssio
nsth
atus
edre
flect
ive
liste
ning
.Se
lf-m
onito
red
diet
ary
fat,
F/V,
grai
nin
take
thro
ugho
utst
udy.
Kcal
:C
vsI:
�24
0.8
vs�
361.
4,P�
0.00
1;ES
�0.
02%
fat:
�0.
6vs
�8.
8%P�
0.00
1F/
V:0.
2vs
1.4
serv
ings
,P�
0.00
1Fi
ber:
�0.
2vs
2.2
,P�
0.00
1.
PA(M
ETS)
:Co
nvs
I0.9
vs1.
1M
ETs,
P�0.
07.
Wei
ght
chan
gedi
ffere
nce
Can
dI
grou
psat
12m
o,1.
9kg
,P�
0.00
1;at
7y,
0.4
kg,
P�0.
01.
…
Look
AHEA
DRe
sear
chGr
oup,
111
2007
,2-
grou
pRC
T/12
mo
(N�
5145
)
Adul
tsw
ithT2
DM,
59%
fem
ale,
63%
whi
te,m
ean
age
59y,
BMI3
5–36
.Re
tent
ion
at1
y:�
96%
Diab
etes
supp
ort
and
educ
atio
nco
nditi
on(D
SE):
4se
ssio
nson
topi
csre
late
dto
diet
and
PA,
noco
unse
ling,
not
wei
ghed
.In
tens
ive
lifes
tyle
inte
rven
tion
(ILI):
Grou
pan
din
divi
dual
mee
tings
toac
hiev
e/m
aint
ain
7%w
eigh
tlo
ssvi
ade
crea
sed
calo
ricin
take
(30%
fat)
and
porti
on-c
ontro
lled
diet
s;in
crea
sed
PA(1
75m
in/w
k);
3gr
oup
mee
tings
�1
indi
vidu
alm
eetin
gm
onth
lydu
ring
mo
1–6,
2gr
oup
mee
tings
�1
indi
vidu
alm
eetin
gm
onth
lyfo
r7–
12m
o.
…Ca
rdio
resp
irato
ryfit
ness
:Fi
tnes
sin
crea
ses
10.8
%in
DSE
vs15
.9%
inIL
I,P�
0.00
1.
Wei
ght
loss
:0.
7%vs
8.6%
ofin
itial
body
wei
ght,
P�0.
0001
.
DSE
vsIL
I:SB
P�
2.8
vs�
6.8,
P�0.
001;
DBP
�1.
8vs
�3.
0,P�
0.00
1;HD
L�
1.4
vs�
3.4,
P�0.
001;
gluc
ose
�7.
2vs
21.5
,P�
0.00
1.
Perr
yet
al,40
2007
,2-
grou
pRC
T/12
wk
(N�
46)
100%
rura
lwom
en,
95%
whi
te,
mea
nag
e45
y,m
ean
educ
atio
n�15
y.
HTH:
Indi
vidu
al�
grou
pco
mpo
nent
s.In
divi
dual
com
pone
ntin
clud
edm
otiv
atio
nali
nter
view
ing
for
30m
inat
base
line
follo
wed
byw
eekl
y10
-min
boos
ter
calls
.W
omen
aske
dto
set
goal
san
dm
onito
rpr
ogre
ssan
dre
ceiv
edin
divi
dual
ized
exer
cise
pres
crip
tion.
Grou
pco
mpo
nent
incl
uded
anu
rse
led
1-h
wee
kly
grou
pw
alk
topr
omot
esu
ppor
tan
dse
lf-ef
ficac
y.Co
mpa
rison
:Su
bjec
tsre
ceiv
eda
brie
f10
-min
indi
vidu
alpr
ivat
ead
vice
sess
ion,
am
onth
ly5-
min
rein
forc
emen
tca
ll,an
indi
vidu
aliz
edex
erci
sepr
escr
iptio
n,an
da
logb
ook
tore
cord
wal
king
.
…Ca
rdio
resp
irato
ryfit
ness
per
dist
ance
wal
ked
in12
-min
wal
kte
st:
Wom
enin
HTH
had
grea
ter
impr
ovem
ent
infit
ness
,P�
0.05
7vs
com
paris
ongr
oup.
……
Stev
ens
etal
,41
2001
,4-
grou
pRC
T(T
OHP
II)/3
6m
o(N
�11
91)
66%
male
,mea
nag
e43
year
s,79
%w
hite
;BM
I31.
Rete
ntion
:92%
and
93%
forw
eight
loss,
89%
and
86%
forB
Pm
easu
re.
UC:
Not
desc
ribed
.W
eigh
tlo
ssin
terv
entio
n(W
LI):
Indi
vidu
alco
unse
ling
follo
wed
by14
wee
kly
grou
pm
eetin
gs;
ther
eafte
r,6
biw
eekl
ygr
oup
mee
tings
.Af
ter
18m
o,op
tions
incl
uded
indi
vidu
alor
grou
pse
ssio
nson
sele
cted
wei
ght-
loss
topi
cs.
Focu
son
beha
vior
alse
lf-m
anag
emen
t,so
cial
supp
ort;
incl
uded
self-
mon
itorin
g,go
alse
tting
,de
velo
ping
actio
npl
ans,
and
prob
lem
solv
ing.
Wei
ght
loss
goal
of�
4.5
kg,
PA30
–45
min
utes
,4–
5/w
k.
……
Wei
ght
loss
:UC
vsW
LI:
�0.
1vs
�4.
4,0.
7vs
�2.
0,an
d1.
8vs
�0.
2kg
at6,
18,
36m
o,P�
001;
ES�
0.10
.
Diffe
renc
ein
scor
es:
SBP
�3.
7,�
1.8,
�1.
3m
mHg
at6,
18,
36m
o,P�
0.01
.DB
P�
2.7,
�3.
5,�
2.0
mm
Hgat
6,18
,36
mo.
P�0.
001–
0.05
;P�
0.00
1–P�
0.05
.
Writ
ing
Grou
pfo
rAc
tivity
Coun
selin
gTr
ial,13
520
01,
RCT/
24m
o(N
�87
4)
55%
mal
es,m
ean
age
51y,
�60
%w
hite
;BM
I29–
30.
Rete
ntio
n:91
.4%
com
plet
edPA
,77
.6%
VO2
max
.
Advi
ce(A
D):
Incl
udes
phys
icia
nad
vice
and
writ
ten
educ
atio
nalm
ater
ials
(reco
mm
ende
dca
re).
Assi
stan
ce(A
S):
Com
pone
nts
ofAD
grou
p�in
tera
ctiv
em
aila
ndbe
havi
oral
coun
selin
gat
phys
icia
nvi
sits
.Co
unse
ling
(Cou
n):
Allo
fAD
and
ASco
mpo
nent
s�re
gula
rte
leph
one
coun
selin
gan
dbe
havi
oral
clas
ses.
…VO
2m
ax:
Sign
ifica
ntly
high
erin
ASth
anAD
grou
p(8
0.8
mL)
,hi
gher
inCo
unth
anin
ADgr
oup
(73.
9m
L);
NSD
inm
en;
ES�
0.07
–0.0
8.
……
RCT
indi
cate
sra
ndom
ized
cont
rolle
dtri
al;I
,int
erve
ntio
ngr
oup;
BP,b
lood
pres
sure
;PCP
,prim
ary
care
prov
ider
;C,c
ontro
lorc
ompa
rison
grou
p;SB
P,sy
stol
icbl
ood
pres
sure
;DBP
,dia
stol
icbl
ood
pres
sure
;NSD
,no
sign
ifica
ntdi
ffere
nce;
ES,e
ffect
size
;LDL
-C,l
ow-d
ensi
tylip
opro
tein
chol
este
rol;
F/U,
follo
w-u
p;DM
,dia
bete
sm
ellit
us;U
C,us
ualc
are;
MET
s,m
etab
olic
equi
vale
nts;
HS,h
igh
scho
ol;F
/V,f
ruits
and
vege
tabl
es;H
DL,h
igh-
dens
itylip
opro
tein
;FF
Q,Fo
odFr
eque
ncy
Ques
tionn
aire
;SC
T,so
cial
cogn
itive
theo
ry;
HMO,
heal
thm
aint
enan
ceor
gani
zatio
n;CV
D,ca
rdio
vasc
ular
dise
ase;
and
Hb,
hem
oglo
bin.
416 Circulation July 27, 2010
Tabl
e3.
RCTs
ofIn
terv
entio
nsto
Prom
ote
PAan
dDi
etar
yLi
fest
yle
Chan
ge:M
inor
itySa
mpl
es
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Grou
p-ba
sed
inte
rven
tion
deliv
ery
stra
tegi
es
Elde
ret
al,11
0
1998
,2-
grou
pcl
uste
rra
ndom
ized
para
llelg
roup
trial
/3-m
opo
stte
stan
d6
mo
(N�
408)
Adul
tsen
rolle
din
Engl
ish
asse
cond
lang
uage
clas
ses,
mea
nag
e28
.7y,
�50
%fe
mal
e,in
US�
3y.
87%
Hisp
anic
,66
%m
onth
lyin
com
e�
$109
9.
Nutri
tion
Hear
t-He
alth
Educ
atio
n:Fi
ve3-
hgr
oup
clas
ses
onnu
tritio
n/he
art
heal
th;
cultu
rally
sens
itive
clas
ses
cond
ucte
din
Engl
ish
and
Span
ish.
Stre
ss-m
anag
emen
tEd
ucat
ion:
Five
3-h
grou
pcl
asse
son
stre
ssm
anag
emen
t.
……
Wei
ght
loss
:Nu
tritio
ngr
oup:
Nolo
ss,
gain
of2.
5lb
at6
mo
vs0.
66lb
gain
inSt
ress
grou
p.14
1.65
lb(n
obe
twee
n-gr
oup
diffe
renc
es).
Tota
lcho
leste
rol,
mg/
dL:N
utrit
iongr
oup
178.
94at
base
line,
169.
88at
6m
o.St
ress
grou
p17
7.03
atba
selin
e,16
6.18
at6
mo.
With
ingr
oup
diffe
renc
e,P�
0.01
.NSD
betw
een
grou
ps.
HDL
chole
ster
ol,m
g/dL
:NSD
with
inor
betw
een
grou
ps.
BPm
mHg
:sig
nific
antw
ithin
-gro
upch
ange
s,P�
0.00
1.NS
Dbe
twee
ngr
oups
.
Hartm
anet
al,96
1997
,qua
si-ex
perim
enta
lde
sign/
8w
ks(N
�20
4)
Low
liter
acy
adul
tsnu
tritio
ned
ucat
ion
prog
ram
for
the
low
inco
me.
94%
fem
ale,
32%
blac
k,57
%in
com
e�
$10
000/
y.
I:Re
ceiv
edlo
w-f
atnu
tritio
ned
ucat
ion
“Hel
pYo
urse
lfto
Heal
th”
infu
nan
den
terta
inin
gfo
rmat
;10
sess
ions
onlo
w-f
atnu
tritio
n,ta
ught
byNu
tritio
nEd
ucat
ion
Assi
stan
tsw
holiv
edin
the
com
mun
ity.
Grou
psm
etat
com
mun
itysi
tes;
liter
acy
leve
ladd
ress
ed.
C:Re
ceiv
edus
ualE
xpan
ded
Food
and
Nutri
tion
Educ
atio
nPr
ogra
m—
food
budg
etin
g,fo
odsa
fety
,an
dhe
alth
yea
ting.
Calo
ries:
per
24-h
reca
ll.En
ergy
/kca
ls:
NSD
with
inor
betw
een
grou
ps.
Tota
lfat
(kca
ls):
NSD
with
inor
betw
een
grou
ps.
……
Tota
lcho
lest
erol
(mg/
dL),
treat
men
tgr
oup:
NSD
with
inor
betw
een
grou
ps.
How
ard-
Pitn
eyet
al,54
2-gr
oup
clus
ter
RCT/
�5
mo
(N�
351)
Adul
tsre
crui
ted
from
adul
ted
ucat
ion
clas
ses.
59%
Hisp
anic
,85
%w
omen
,66
%ha
dre
adin
gle
vela
tsi
xth
grad
ele
velo
rbe
low
,65
%fa
mily
inco
me
�$1
000
0/y.
I:A
diet
ary
fat
curr
icul
umof
fere
dov
er20
mo;
2pa
rts,
6w
ksin
clas
sroo
mfo
llow
edby
a12
-wk
mai
nten
ance
inte
rven
tion;
taug
htby
nutri
tion
educ
ator
s;si
x90
-min
,w
hich
wer
ein
tera
ctiv
ew
ithfe
ww
ritte
nm
ater
ials
,pl
ussk
illbu
ildin
g,fo
odta
stin
gs,
and
dem
onst
ratio
nsof
low
-fat
goal
sse
tby
parti
cipa
nts.
12-w
km
aint
enan
cein
terv
entio
n(ie
,co
ntac
tev
ery
2w
ksby
tele
phon
eor
mai
lfor
6co
ntac
ts(to
prov
ide
supp
ort
and
enco
urag
emen
t);m
etho
dsan
dm
ater
ials
tailo
red
for
adul
tw
ithlo
wlit
erac
y.C:
Gene
raln
utrit
ion
clas
ses
taug
htby
para
prof
essi
onal
educ
atio
n;de
sign
edto
impr
ove
know
ledg
ean
dnu
tritio
nch
oice
s.Ad
dres
sed
food
pyra
mid
,fo
odsa
fety
and
mea
lpla
nnin
g.
Tota
lfat
:pe
rFF
Q%
cals
from
fat,
chan
gefro
mba
selin
e,I�
37.1
%–3
3.2%
;vs
C�36
.4%
–35.
2%.
Sign
ifica
ntw
ithin
-gro
updi
ffere
nce,
for
I:P�
0.01
.No
betw
een-
grou
pdi
ffere
nces
.To
talf
at(g
/d):
NSD
with
inor
betw
een
grou
ps.
…BM
I:ch
ange
from
base
line.
NSD
with
ingr
oup
orbe
twee
ngr
oups
.
Chol
este
rol(
mg/
dL):
chan
gefro
mba
selin
e.NS
Dw
ithin
grou
por
betw
een
grou
ps.
Kum
anyi
kaet
al,42
2005
,2-
phas
etri
al,
phas
e1
all
rece
ived
grou
pcl
asse
s;ph
ase
II2-
grou
pRC
T/12
mo
(N�
87co
mpl
eted
phas
eII)
100%
blac
k,90
%fe
mal
e,m
ean
age
�44
.4y,
�67
%ed
ucat
ion
�12
y,m
ean
BMI3
7.5.
Phas
eI—
Grou
pco
unse
ling
prog
ram
(HEL
P):
Alli
nter
este
dpa
rtici
pant
sen
rolle
din
10w
eekl
ygr
oup
wei
ght
loss
clas
ses;
nosp
ecifi
cdi
etor
calo
ricin
take
spec
ified
;su
bjec
tsen
cour
aged
tose
tpe
rson
algo
als
and
tose
lf-m
onito
rdi
et;
advi
ceto
incr
ease
PAw
asin
divi
dual
lyta
ilore
dto
abili
tyan
dpr
efer
ence
.3
mo
afte
ren
rollm
ent
subj
ects
rand
omiz
edto
phas
eII
inte
rven
tions
:Cl
asse
s:HE
LPcl
asse
s�gr
oup
coun
selin
gof
fere
dbi
wee
kly,
then
mon
thly
vsw
eekl
y.En
hanc
edse
lf-he
lp:
Staf
ffa
cilit
ated
self-
help
;su
bjec
tsre
ceiv
eda
pers
onal
ized
cale
ndar
,a
pack
ets
desc
ribin
glo
calr
esou
rces
,a
pers
onal
diar
y,a
pedo
met
er,
and
adho
cte
leph
one
supp
ort.
UC:
Nofu
rther
coun
selin
gou
tsid
ebr
ief
coun
selin
gat
sem
iann
ualc
linic
visi
ts.
……
Wei
ght
loss
(kg)
:�
1.2�
5.2
over
entir
est
udy
perio
d,P�
0.05
.Ne
ither
HELP
clas
ses
nor
self-
help
was
supe
rior
toUC
durin
gph
ase
II.
SBP
(mm
Hg):
�6.
5�11
over
entir
est
udy
perio
d,P�
0.01
;DB
P(m
mHg
):�
4.9�
6.8.
Nosi
gnifi
cant
chan
ges
into
tal
chol
este
rol,
trigl
ycer
ides
,or
bloo
dgl
ucos
e.
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 417
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
McN
abb
etal
,43
1997
,2-
grou
pRC
T/1
wk
afte
rI
finis
hed
(N�
39)
Wom
enre
crui
ted
from
3ur
ban
blac
kch
urch
es.
Mea
nag
e56
y,BM
I�30
,13
%�
HSed
ucat
ion,
appr
oxim
atel
y54
%em
ploy
ed
I:PA
THW
AYS
prog
ram
:14
-wk
smal
llay
-led
cultu
rally
sens
itive
grou
pse
ssio
nsat
chur
chon
diet
that
incl
uded
goal
setti
ng,
prob
lem
solv
ing,
and
inst
ruct
ions
toen
gage
inre
crea
tiona
lwal
king
adm
inis
tere
dby
lay
faci
litat
ors
atth
ech
urch
es;
incl
uded
use
ofet
hnic
food
s.C:
Wai
t-lis
tco
ntro
l.
……
Wei
ght
loss
(lb):
�10
.0�
10.2
8vs
C�
1.9�
4.25
,P�
0.00
01.
BMI(
kg/m
2 ):Ig
roup
�1.
4�1.
61vs
Cgr
oup
0.6�
0.73
,P�
0.00
01,
ES�
0.65
.
…
Indi
vidu
al-b
ased
inte
rven
tion
deliv
ery
stra
tegi
es
Ahlu
wal
iaet
al,93
2007
,cl
uste
rra
ndom
ized
trial
of20
publ
icho
usin
gde
velo
pmen
ts/6
mo
(N�
173)
100%
smok
ers,
mea
nag
e45
.5y,
81.3
%bl
ack,
�38
%HS
educ
atio
n,42
%un
empl
oyed
,�
73%
mon
thly
inco
me
�$8
00.
Both
arm
sre
ceiv
ed5
sess
ions
ofm
otiv
atio
nali
nter
view
ing
coun
selin
gfo
rF/
Vor
smok
ing
cess
atio
n.Se
lf-ef
ficac
yan
dba
lanc
ing
pros
and
cons
ofch
ange
and
2-di
men
sion
alm
odel
ofcu
ltura
lsen
sitiv
itygu
ided
inte
rven
tions
.Fr
uit
and
vege
tabl
ein
terv
entio
n(F
/V):
Rece
ived
aba
gof
fresh
F/Vs
,a
cook
book
ofhe
alth
yre
cipe
s,di
etar
yed
ucat
ion
mat
eria
ls,
and
2vi
deos
onF/
Vs.
Smok
ing
cess
atio
nin
terv
entio
n(S
C):
Rece
ived
an8-
wee
ksu
pply
ofni
cotin
egu
man
din
stru
ctio
nsab
out
quitt
ing.
F/V:
At8
wee
ksan
d6
mo,
the
F/V
grou
pco
nsum
ed1.
58(P
�0.
001)
and
0.78
(P�
0.04
),re
spec
tivel
y,m
ore
F/V
serv
ings
per
day
than
SC.
Com
plet
ing
mor
em
otiv
atio
nali
nter
view
sess
ions
(P�
0.02
)an
dtry
ing
mor
ere
cipe
s(P
�0.
02)
led
tosi
gnifi
cant
lygr
eate
rin
crea
seof
F/Vs
inth
eF/
Vgr
oup.
……
…
Eaki
net
al,44
2007
,2-
grou
pRC
T/6
mo
(N�
200)
Adul
tsw
ith�
1ch
roni
cco
nditi
ons.
Mea
nag
e49
.5y,
75%
Hisp
anic
,�
5y
inUS
,79
%fe
mal
e,�
36%
�$1
000
0/y.
I:Bi
lingu
alhe
alth
educ
ator
prov
ided
2-in
divi
dual
sess
ions
onPA
and
diet
ary
reco
mm
enda
tions
(60–
90m
in)
3m
oap
art
atho
me
orcl
inic
;fe
edba
ckon
base
line
asse
ssm
ent;
parti
cipa
nts
chos
ePA
and
diet
goal
;go
alse
tting
,fe
edba
ckan
dpr
oble
mso
lvin
gpl
usID
ofm
ultil
evel
/co
mm
unity
supp
orts
for
heal
thbe
havi
orch
ange
emph
asiz
ed.
3fo
llow
-up
tele
phon
eca
llsdu
ring
6-m
oin
terv
entio
n;lo
w-li
tera
cyle
tters
rem
inde
dpa
rtici
pant
sof
goal
s,ad
dres
sed
barr
iers
,an
dsu
gges
ted
reso
urce
s;al
lact
iviti
esad
apte
dto
liter
acy
leve
l(vi
sual
aids
)an
dcu
lture
;in
terv
entio
nstra
nsla
ted
into
Span
ish
and
valid
ated
.UC
:Su
bjec
tsw
ere
mai
led
alo
calc
omm
unity
reso
urce
sgu
ide
and
3ne
wsl
ette
rson
finan
cial
man
agem
ent.
Fat/f
iber
inta
kepe
rse
lf-re
port
ques
tionn
aire
:At
6-m
onth
the
Igr
oup
had
sign
ifica
ntly
bette
rFa
t/fib
erin
take
com
pare
dw
ithUC
grou
p,P�
0.05
.
PA:
Chan
gefro
mB
inm
inut
esw
alke
d,NS
Dw
ithin
orbe
twee
ngr
oups
.
……
Elde
ret
al,14
4
2006
,3-
grou
pRC
T/12
mo
(N�
367)
Latin
aw
omen
,m
ean
age
39.7
�9.
9y,
BMI2
8.9–
30.4
.Re
tent
ion
76%
–82%
for
3gr
oups
.
Tailo
red
(T):
12ta
ilore
dpr
int
new
slet
ters
with
hom
ewor
kas
sign
men
tsm
aile
dw
eekl
y.Pr
omot
ora
(P):
Wee
kly
hom
evi
sits
orte
leph
one
calls
byla
yad
viso
rov
er14
wks
�12
tailo
red
new
slet
ters
and
hom
ewor
k.As
sess
men
tat
base
line,
12w
ks,
and
6an
d12
mo.
C:12
off-
the-
shel
fm
ater
ials
mai
led
wee
kly
toho
me.
Kcal
:Pr
omot
ora
1288
.7vs
Tailo
red
1420
.6vs
C14
30.5
;P�
0.01
8at
12w
ks,
NSD
at6
and
12m
o.Fa
t:Pr
omot
ora
43.1
gvs
Tailo
red
49.8
g,C
49.1
g;P�
0.02
8at
12w
ks,
NSD
at6
and
12m
o;ES
�0.
14.
……
…
(Con
tinue
d)
418 Circulation July 27, 2010
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Jaco
bset
al,45
2004
,cl
uste
rra
ndom
ized
trial
of22
heal
thde
partm
ents
/12
mo
(N�
421)
100%
low
-inco
me
fem
ale,
mea
nag
e59
y,51
%�
HSed
ucat
ion,
44%
from
ethn
icm
inor
itygr
oups
.
Alls
ubje
cts
prev
ious
lypa
rtici
pate
din
a1-
ydi
etan
dPA
beha
vior
chan
gepr
ogra
m(p
hase
II):
North
Caro
lina
WIS
EWOM
AN,
inw
hich
heal
thde
partm
ents
wer
era
ndom
ized
toth
een
hanc
edin
terv
entio
nor
the
min
imal
inte
rven
tion.
Inph
ase
III,
ofth
e22
heal
thde
partm
ents
who
had
rece
ived
the
enha
nced
inte
rven
tion
inph
ase
II,11
wer
era
ndom
ized
toM
aint
enan
ceSp
ecia
lInt
erve
ntio
nan
d11
wer
era
ndom
ized
toM
aint
enan
ceUs
ualC
are.
Mai
nten
ance
Spec
ialI
nter
vent
ion
(MSI
):Su
bjec
tsw
ere
mai
led
6bi
mon
thly
com
pute
r-ta
ilore
dhe
alth
mes
sage
san
dre
ceiv
ed2
tele
phon
eca
llsfro
mhe
alth
depa
rtmen
tst
aff.
Inte
rven
tion
mat
eria
lsw
ere
base
don
soci
alco
gniti
veth
eory
,re
laps
epr
even
tion
theo
ry,
and
the
trans
theo
retic
alm
odel
.Ta
ilorin
gw
asac
cord
ing
togo
als,
stag
eof
chan
ge,
know
ledg
e,so
cial
supp
ort
syst
ems,
high
-ris
ksi
tuat
ions
for
rela
pse,
and
perc
eive
dbe
nefit
san
dba
rrie
rs.
Mes
sage
sw
ere
desi
gned
for
low
-lite
rate
and
low
-inco
me.
Mai
nten
ance
Usua
lCar
e(M
UC):
Rece
ived
usua
lfol
low
-up
serv
ices
atth
edi
scre
tion
ofth
ehe
alth
depa
rtmen
ts.
Basi
cnu
tritio
nan
dPA
coun
selin
gpa
mph
lets
wer
eav
aila
ble.
Both
grou
psm
aint
aine
dlo
wre
porte
din
take
leve
lsof
diet
ary
satu
rate
dfa
tan
dch
oles
tero
l.
Both
grou
psm
aint
aine
dlo
wle
vels
ofse
lf-re
porte
dPA
.Su
bjec
tsin
MSI
wer
em
ore
likel
yto
mov
efo
rwar
din
tom
ore
adva
nced
stag
esof
PA,
P�0.
02.
……
Resn
icow
etal
,103
2005
,3-
grou
pcl
uste
rra
ndom
ized
trial
/1y
(N�
906)
Mea
nag
e46
.3y,
76.2
%fe
mal
e,10
0%bl
ack,
60%
inco
me
�$4
000
0/y,
�70
%so
me
colle
ge.
C:St
anda
rdco
mm
erci
alse
lf-he
lpvi
deos
and
broc
hure
sm
atch
edfo
rin
tens
ityan
dty
pew
ithgr
oup
2m
ater
ials
.Cu
ltura
llyta
rget
edse
lf-he
lpnu
tritio
nan
dPA
:Cul
tura
llyta
ilore
dnu
tritio
nvid
eo,c
ookb
ook,
exer
cise
video
,exe
rcise
guid
e,an
dau
dio
cass
ette
.M
otiva
tiona
lInt
ervie
w(M
I)pl
usgr
oup
2in
terv
entio
n:4
MIs
essio
nsde
liver
edby
tele
phon
eat
4,12
,26,
and
40w
ks.T
wo
calls
addr
ess
F/V
and
2ca
llad
dres
sed
PA.S
elf-h
elp
mat
eria
lsre
view
eddu
ring
calls
.
F/V:
MIi
ncre
ased
F&V
inta
keco
mpa
red
with
othe
r2
grou
ps,
P�0.
05.
PA:
Tota
lmin
/wk
ofPA
incr
ease
din
Cultu
rala
ndM
Igr
oups
com
pare
dw
ithC,
P�0.
05.
NSD
betw
een
cultu
rean
dM
I.
……
Mul
ticom
pone
ntin
terv
entio
nde
liver
yst
rate
gies
Albr
ight
etal
,46
2005
,2-
grou
pRC
T/10
wks
,6
mo,
and
1y
(N�
72)
Sede
ntar
ylo
w-in
com
ew
omen
recr
uite
dfro
mad
ult
educ
atio
nsi
tes,
mea
nag
e32
y,73
%Hi
span
ic,
�70
%in
com
e�
$20
000/
y.
Allr
ecei
ved
8w
eekl
y1-
hPA
skill
-bui
ldin
gcl
asse
sta
ught
byet
hnic
ally
mat
ched
educ
ator
s;in
clud
edsm
allg
roup
disc
ussi
ons
and
Q&A;
Goal
30m
inof
mod
erat
ePA
5da
ys/w
k.Af
ter
clas
ses,
subj
ects
rand
omiz
edto
:Ho
me-
base
dte
leph
one�
mai
lsup
port
(P�
MS)
:W
eekl
yte
leph
one
coun
selin
gfo
rfir
st4
wks
,bi
wee
kly
for
8w
ks,
then
mon
thly
,ca
lls10
mo;
pedo
met
ers,
acco
mpa
nied
byco
unse
ling
and
prov
isio
nof
feed
back
;w
omen
prov
ided
larg
em
agne
tic,
eras
able
mon
thly
cale
ndar
toat
tach
tore
frige
rato
ran
dre
cord
num
ber
ofst
eps.
Hom
e-ba
sed
mai
lsup
port
(MS)
:M
onth
lyne
wsl
ette
rsw
ithpo
stag
epa
idm
ail-b
ack
card
tore
port
num
ber
ofst
eps
and
PAin
last
wee
k;fe
edba
cksh
eets
wer
ese
ntfro
mhe
alth
educ
ator
base
don
resp
onse
s;pr
izes
earn
edfo
rm
ailin
gba
ck(e
g,pe
ns,
wai
stpa
cks,
mug
s).
Both
grou
psin
corp
orat
edpe
ople
,pl
aces
,la
ngua
ge,
and
clot
hing
fam
iliar
tocu
lture
;ad
dres
sed
core
valu
es.
…PA
:At
10-w
kP�
MS�
263
kcal
/wk
vsM
S29
4kc
al/w
k,NS
Dbe
twee
nor
with
ingr
oups
.10
-wee
kto
12m
och
ange
,P�
MS:
adde
din
crea
seof
52kc
al/w
kvs
MS:
1014
kcal
/wk
less
,be
twee
ngr
oup
diffe
renc
e,P�
0.04
5,ES
�0.
24.
……
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 419
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Bulle
ret
al,74
1999
,2-
grou
pRC
T/6
and
18m
o(N
�76
6)
Empl
oyee
sfro
m93
wor
kgr
oups
.M
ean
age
43y,
43%
Hisp
anic
,6%
blac
k,75
%m
en,
�13
%�
11th
grad
eed
ucat
ion.
Allr
ecei
ved
gene
ral5
-a-d
ayin
foov
er18
mo.
Peer
Educ
atio
n(P
E):
last
9m
onth
sof
the
gene
ralp
rogr
am.
Subj
ects
had
indi
vidu
alse
ssio
nsw
ithpe
erle
ader
and
peer
-led
grou
pdi
scus
sion
sab
out
F/V;
activ
ities
for
child
ren;
prin
tm
ater
ials
abou
tF/
V.M
ater
ials
tosu
ppor
tbe
havi
oral
skill
s(ie
,F/
Vca
lend
ar,
reci
pes)
;ad
dres
sed
cultu
ralt
rend
sin
diet
,lo
w-li
tera
cygr
aphi
cs,
and
stor
ies.
Gene
ralE
duca
tion
only
:No
peer
educ
atio
ndu
ring
last
9m
o.
F/V:
inPE
grou
pat
18m
o,0.
77an
d0.
46in
crea
ses
inda
ilyF/
Vse
rvin
gspe
rFF
Q,an
dre
call
P�0.
001,
P�0.
002,
resp
ectiv
ely.
……
…
Cam
pbel
let
al,76
1999
,cl
uste
rra
ndom
ized
2-gr
oup
RCT/
2y
(N�
2519
)
Recr
uite
dfro
m50
blac
kch
urch
esin
10ru
ralN
orth
Caro
lina
coun
ties.
98%
blac
k,m
ean
age
53.8
y,73
%fe
mal
e,59
%in
com
e�
$20
000,
67%
�HS
educ
atio
n.
I:5-
a-da
ypr
ogra
m—
20-m
oin
divid
ual,
soci
alne
twor
kan
dco
mm
unity
-leve
lac
tiviti
esem
phas
izing
F/V
�2
educ
atio
nals
essio
nsre
gard
ing
mod
ifyin
gco
okin
gm
etho
ds,s
erve
dm
ore
F/V
atch
urch
func
tions
;com
mun
ityco
aliti
ons
incl
uded
chur
chm
embe
rs,l
ocal
agen
cies
,gro
cers
,and
farm
ers
topl
anco
mm
unity
even
ts;c
hurc
h-in
itiat
edac
tiviti
es.M
ater
ials
prom
oted
loca
llygr
own
prod
uce;
lay
heal
thad
visor
sat
tend
edbi
mon
thly
train
ing
sess
ions
topr
ovid
eso
cial
supp
orta
ndad
vanc
est
age
ofch
ange
;pas
tors
prom
oted
proj
ect.
C:De
laye
din
terv
entio
n—no
prog
ram
until
the
final
follo
w-u
p.
F/V
serv
ings
per
FFQ:
at2-
yfo
llow
-up,
the
5-a-
day
grou
pco
nsum
ed0.
85F/
Vse
rvin
gsm
ore
than
the
dela
yed
inte
rven
tion
grou
p,P�
0.00
1.
……
…
Coat
eset
al,47
1999
,2-
grou
pRC
T/6,
12,
18m
os(N
�22
08)
100%
fem
ale,
mea
nag
e60
y,28
%bl
ack,
16%
Hisp
anic
,re
crui
ted
from
clin
ics
loca
ted
in3
sout
hern
stat
es,
16%
�$1
500
0in
com
e,11
%�
HSed
ucat
ion.
I:Va
ngua
rdW
omen
’sHe
alth
Tria
lmod
ified
toin
clud
ead
ditio
nalg
oals
.A
nutri
tioni
stas
sign
edpe
rson
alfa
tg
goal
san
dde
liver
ed�
10gr
oup
sess
ions
with
decr
easi
ngfre
quen
cyov
er2-
ype
riod.
For
indi
vidu
als
havi
ngdi
fficu
lty,
nutri
tioni
sts
prov
ided
indi
vidu
aliz
edse
ssio
ns;
each
sess
ion
incl
uded
nutri
tion
and
beha
vior
chan
gest
rate
gies
,cu
ltura
l(re
gion
al/e
thni
cfo
ods)
,la
ngua
gean
dlo
w-li
tera
cyse
nsiti
vein
form
atio
nw
asus
ed;
sess
ions
incl
uded
regi
onal
and
ethn
icfo
ods.
Staf
ffro
mva
ried
raci
al/e
thni
cba
ckgr
ound
s.C:
Subj
ects
rece
ived
pack
age
ofst
anda
rdm
ater
ials
ongo
oddi
etar
ypr
actic
esin
clud
ing
the
Diet
ary
Guid
elin
esfo
rAm
eric
ans.
CalE
nerg
y(k
cal):
At18
mo,
betw
een-
grou
p(I
vsC)
diffe
renc
eof
�23
3(�
355,
�11
1);F
ruits
(ser
vings
):I-C
diffe
renc
eof
0.53
(0.3
3,0.
73);
Vege
tabl
es(s
ervin
gs):
I-Cdi
ffere
nce
of0.
27(0
.07,
0.47
);Fa
t(%
ofen
ergy
):I-C
diffe
renc
eof
�11
.62
(�13
.07,
�10
.17)
;Sat
Fat%
ofen
ergy
:I-C
diffe
renc
eof
�3.
54(�
4.09
,�2.
99);
chol
este
rol
(mg)
:�74
.1(�
100.
5,�
47.6
).
……
…
Frie
set
al,81
2005
,2-
grou
pRC
T/1,
6,an
d12
mo
(N�
622)
Indi
vidu
als
from
3ru
ralV
irgin
iaph
ysic
ian
prac
tices
.36
.7%
blac
k,m
ean
age
46y,
65%
fem
ale,
17%
�$2
000
0/y
inco
me.
I:Ta
ilore
dfe
edba
ckpl
usse
lf-he
lp.
Feed
back
mai
led
and
incl
uded
aPC
Ple
tter,
2fe
edba
ckfo
rms
(fat
and
fiber
),an
d2
reco
mm
enda
tion
form
s(fa
t/fib
er).
Stru
ctur
edte
leph
one
coun
selin
gw
ithin
2w
ksto
rein
forc
em
aile
dfe
edba
ck,
addr
ess
need
sof
low
liter
ate.
Low
-lite
racy
self-
help
book
lets
mai
led
wee
kly
�4.
Acu
ltura
l,co
mm
unity
advi
sory
boar
dm
ade
deci
sion
sab
out
cont
ent
and
pict
ures
inin
terv
entio
nm
ater
ial.
C:De
laye
din
terv
entio
n.
Fibe
r:pe
rfa
tan
dfib
erqu
estio
nnai
re,
high
ersc
ores
�m
ore
fiber
.Ig
roup
:2.
24(0
.35)
atba
selin
e,2.
07(3
7)at
6m
o2.
12(0
.39)
at12
mo
vsC
grou
p:2.
24(0
.36)
atba
selin
e,2.
16(0
.37)
at6
mo,
and
2.16
(0.3
8)at
12m
o.Fa
tper
ques
tionn
aire
,low
ersc
ores
�le
ssdi
etar
yfa
t:Ig
roup
:0.
2.03
(0.3
5)at
base
line,
1.85
(0.3
4)at
6m
o,1.
87(0
.35)
at12
mo,
vsC
grou
p:2.
05(0
.33)
atba
selin
e,1.
97(0
.34)
at6
mo,
1.95
(0.3
4)at
12m
o.Fo
rfa
tan
dfib
er,I
grou
psig
nific
ant
impr
ovem
ento
ver
time
P�0.
05);
inte
ract
ion
betw
een
cond
ition
and
time
signi
fican
tP�
0.05
.
……
…
(Con
tinue
d)
420 Circulation July 27, 2010
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Hava
set
al,48
1998
,2-
grou
pra
ndom
ized
cros
sove
rde
sign
/8m
oan
d1
y(N
�31
22)
Wom
ense
rved
by16
WIC
prog
ram
sin
Mar
ylan
d.52
%bl
ack,
�66
%ag
e�
30y,
19%
�HS
educ
atio
n,ap
prox
imat
ely
44%
usin
gfo
odst
amps
.
I:3
com
pone
nts—
(1)
Stag
eof
chan
ge–
base
dnu
tritio
nse
ssio
nsco
nduc
ted
bype
ered
ucat
ors;
(2)
prin
ted
mat
eria
lsan
dvi
sual
rem
inde
rs;
(3)
dire
ctm
ail.
Thre
epe
er-le
d45
-min
grou
pdi
scus
sion
sov
er6-
mo
perio
d,go
al-b
ased
.St
ory-
base
dpr
int
mat
eria
lsan
dvi
deot
apes
abou
tF/
Vw
ere
used
.C:
Inte
rven
tion
dela
yed.
F/V:
Chan
gebe
twee
nba
selin
ean
d8
mo,
Igro
up�
0.56
�0.
11se
rvin
gsvs
Cgr
oup
�0.
13�
0.17
,be
twee
ngr
oup
P�0.
002.
At1
y,Ig
roup
adde
din
crea
seof
�0.
27�
0.09
serv
ings
vsC
grou
p�
0.27
�0.
06se
rvin
gs;
betw
een-
grou
pdi
ffere
nce,
P�0.
004
ES�
0.05
.
……
…
Keys
erlin
get
al,49
2002
,3-
grou
pRC
T/12
mo
(N�
167)
100%
wom
enw
ithty
pe2
DM,
100%
blac
k,m
ean
age
59y,
�33
%in
com
e�
$10
000/
y
A.Cl
inic
and
com
mun
ity:
Incl
inic
—4
mon
thly
visi
tsw
itha
nutri
tioni
stw
hoco
unse
led
abou
tdi
etan
dPA
and
tailo
red
itto
base
line
prac
tices
and
attit
udes
.In
com
mun
ity—
3gr
oup
sess
ions
and
12m
onth
lyte
leph
one
calls
from
ape
erco
unse
lor
who
prov
ided
soci
alsu
ppor
tan
dre
info
rced
beha
vior
chan
gego
als.
B.Cl
inic
only
:Sa
me
ascl
inic
desc
ribed
abov
e.C.
Min
imal
inte
rven
tion:
Educ
atio
nalp
amph
lets
mai
led
tosu
bjec
ts.
…PA
per
acce
lero
met
er:
Avs
Cgr
oups
,th
edi
ffere
nce
inad
just
edm
ean
for
PAw
as44
.1kc
al/d
,P�
0.00
5.B
vsC,
the
diffe
renc
ew
as33
.1kc
al/d
,P�
0.02
9.
……
Kum
anyi
ka,75
1999
,2-
grou
pRC
T/1
y(N
�33
0)
Blac
kad
ults
recr
uite
dfro
msu
perm
arke
tBP
scre
enin
gsag
ed40
–70
y.�
72%
fem
ale,
47%
liter
acy
less
than
eigh
thgr
ade
52%
�$1
500
0/y.
Alls
ubje
cts
tore
duce
fat,
chol
este
rol,
and
Nain
diet
bya
nutri
tioni
stev
ery
4m
oat
offic
evi
sits
.Al
lsub
ject
sre
ceiv
edso
me
CARD
ESm
ater
ials
that
cons
iste
dof
(a)
food
card
sw
ithph
otos
ofco
mm
onfo
ods
and
code
dw
ithsy
mbo
lsto
indi
cate
low
,m
ediu
m,
orhi
ghfa
t,ch
oles
tero
l,or
Naco
nten
t;(b
)a
42-p
age
nutri
tion
guid
e;(c
)25
-min
vide
oto
mot
ivat
ean
dsu
ppor
tch
ange
;an
d(d
)12
,10
–15-
min
audi
otap
esan
dac
com
pany
ing
wor
kshe
ets
topr
ovid
ein
fo.
CARD
ESm
ater
ials
wer
eat
fifth
toei
ghth
grad
ere
adin
gle
vels
.Fu
llIn
stru
ctio
n(F
):Su
bjec
tspa
rtici
pate
din
mon
thly
nutri
tion
clas
ses
for
4m
oaf
ter
enro
llmen
tin
whi
cha
CARD
ESvi
deo
was
view
ed;
guid
ance
prov
ided
abou
tau
diot
apes
and
wor
kshe
ets,
and
disc
ussi
onof
them
esin
audi
opr
ogra
ms.
Vide
opo
rtray
edAf
rican
Amer
ican
fam
ily.
Self-
Help
(SH)
:In
addi
tion
toco
unse
ling
ever
y4
mo,
subj
ects
rece
ived
self-
help
mat
eria
lsin
clud
ing
food
card
san
dnu
tritio
ngu
ide.
……
…Al
lNSD
betw
een
grou
ps.
Chan
gefro
mba
selin
e:To
tal
chol
este
rol
(mm
ol/L
):F
�0.
41�
0.07
fem
ale,
�0.
50�
0.12
mal
e,P�
0.00
01,
vsSH
�0.
43�
0.07
F,�
0.36
�0.
13m
ol/L
,P�
0.00
6.HD
L-C
(mm
ol/L
):F
0.3
(0.0
3)fe
mal
e,0.
01(0
.04)
mal
evs
SH�
0.02
(0.0
3)fe
mal
e,�
0.03
(0.0
5)m
ale.
NSD
with
in-g
roup
diffe
renc
e.LD
L-C
(mm
ol/L
):F
�0.
34(0
.07)
fem
ale,
�0.
36(0
.11)
mal
e,w
ithin
grou
pP�
0.00
1,vs
SH�
0.35
(0.0
7)fe
mal
e,�
0.31
(0.1
2)m
ale;
with
ingr
oup
P�0.
009.
SBP
(mm
Hg):
F�
7.4
(1.9
)vs
SH�
10.6
(1.9
),w
ithin
-gro
updi
ffere
nce,
P�0.
0001
.DB
P(m
mHg
):F
�3.
7(1
.1),
P�0.
0007
vsSH
grou
p�
6.6
(1.1
),P�
0.00
01.
(Con
tinue
d)
Artinian et al Promoting Physical Activity and Dietary Changes 421
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Race
tteet
al,51
2001
,qua
si-ex
perim
enta
l/1y
(N�
69)
100%
blac
k,em
ploy
ees
ofth
eUn
iver
sity
ofW
ashi
ngto
nm
edic
alce
nter
atris
kfo
rty
pe2
DM,
86%
fem
ale,
educ
atio
nan
din
com
eno
tre
porte
d.
I:As
sign
eddi
etgo
als
(ie,
decr
ease
fat
�14
g/d)
.Su
bjec
tsre
ceiv
eda
1-w
ken
ergy
-an
dfa
t-re
stric
ted
diet
prep
ared
bya
met
abol
icki
tche
nfo
llow
edby
alif
esty
lepr
ogra
man
din
crea
sed
PAfo
r1
year
.Su
bjec
tsre
ceiv
edPA
pres
crip
tion
and
help
abou
tho
wto
mee
tgo
als,
7-d
food
diar
ies
ever
y4
mo
and
exer
cise
logb
ooks
.Th
ere
wer
e:in
divi
dual
mee
tings
onre
ques
tov
er1-
ype
riod;
optio
nalb
imon
thly
grou
pm
eetin
gs;
mon
thly
tele
phon
eca
llsto
mai
ntai
nco
ntac
t.C:
Subj
ects
mat
ched
for
age,
body
wei
ght,
body
com
posi
tion,
and
gluc
ose
tole
ranc
e.Su
bjec
tsw
ere
invi
ted
toen
roll
inth
ein
terv
entio
non
com
plet
ion
ofth
est
udy.
……
Wei
ght
loss
:�
4.6
kgin
Ivs
�
0.3
kgin
C,P�
0.00
1.To
talc
hole
ster
ol(m
mol
/L):
�0.
3in
Ivs
�0.
4in
C,P�
0.00
1.Gl
ucos
eto
lera
nce
(GT)
:At
base
line
13in
Ihad
impa
ired
GT,
and
6ha
ddi
abet
icGT
;at
1y,
10ha
dno
rmal
GT,
4ha
dim
paire
dGT
,an
d5
had
diab
etic
GT.
Cont
rol:
nodi
ffere
nce
from
base
line.
Resn
icow
etal
,102
2001
,cl
uste
rra
ndom
ized
trial
/12
mo
(N�
861)
100%
blac
kch
urch
mem
bers
,m
ean
age
43.9
y,73
.3%
fem
ale,
�45
%ha
din
com
e�
$40
000,
�50
%ha
dat
leas
tso
me
colle
ge.
A.Co
mpa
rison
:St
anda
rdnu
tritio
nan
dcu
ltura
llyse
nsiti
veF/
Ved
ucat
ion
mat
eria
ls.
B.Se
lf-he
lp�
1cu
eca
ll:Se
lf-he
lpm
ater
ials
incl
uded
avi
deo,
cook
book
,pr
inte
ded
ucat
ion
mat
eria
ls,
quar
terly
new
slet
ters
,an
dot
her
cues
(mag
net,
pot-
hold
er,
eras
able
writ
ing
tabl
et).
Calls
prov
ided
cues
tous
ein
terv
entio
nm
ater
ials
.C.
Mul
ticom
pone
nt:
Mul
ticom
pone
ntse
lf-he
lpm
ater
ials
with
1cu
eca
llan
d3
mot
ivat
iona
lint
ervi
ewin
gco
unse
ling
calls
.
F/V:
Chan
gein
F/V
was
sign
ifica
ntly
grea
ter
ingr
oup
Cvs
grou
pA
orB.
The
net
diffe
renc
ebe
twee
ngr
oup
Aan
dC
was
1.38
,1.
03,
and
1.21
serv
ings
ofF/
Vpe
rda
yfo
rth
e2-
,7-
,an
d36
-item
FFQs
,re
spec
tivel
y.Th
ene
tdi
ffere
nce
betw
een
grou
pA
and
Bw
as1.
14,
1.10
,an
d0.
97.
……
…
Rosa
let
al,52
2005
,2-
grou
pRC
T/3
and
6m
o(N
�25
)
Adul
tsw
ithty
pe2
DMre
crui
ted
from
aco
mm
unity
.10
0%Hi
span
ic,
80%
fem
ale,
mea
nag
e62
.6y,
84%
�$1
000
0/y,
74%
less
than
oreq
ualt
oei
ghth
grad
e.
Allp
artic
ipan
tsre
ceiv
eda
book
let
desc
ribin
gim
porta
nce
oflif
esty
lefa
ctor
sin
DMan
dpr
ovid
ing
reco
mm
enda
tions
for
diet
,PA
,an
dSM
BG.
I:In
itial
1-h
indi
vidu
alse
ssio
npl
ustw
o15
-min
indi
vidu
alse
ssio
ns,
follo
wed
by10
wee
kly
2.5–
3h
grou
pse
ssio
nsan
dtw
o15
-min
indi
vidu
alse
ssio
nson
diab
etes
;ta
ilore
dto
liter
acy
leve
land
cultu
re,
incl
uded
:se
lf-m
onito
ring
logs
,st
epco
unte
rs.
Abi
lingu
alnu
rse,
nutri
tioni
st,
and
anas
sist
ant.
Inte
rven
tioni
stbi
lingu
alan
dkn
own
inco
mm
unity
.C:
Subj
ects
only
rece
ived
the
book
let
rece
ived
byal
lpar
ticip
ants
.
…NS
Din
incr
ease
dPA
betw
een
orw
ithin
grou
ps.
BMI:
NSD.
HbA1
c:de
crea
seat
6m
onth
sin
Iw
as�
0.85
%vs
�0.
12%
,P�
0.01
.To
talc
hole
ster
ol(m
g/dL
):�
2.0
inI,
�11
.2in
Cat
6m
o,NS
D.LD
L(m
g/dL
):�
3.2
inIv
s�
12.5
inC
at6
mo,
NSD.
SBP
and
DBP:
NSD.
Stat
enet
al,53
Ariz
ona
WIS
EWOM
AN,
2004
,3-
grou
pRC
T/12
mo
(N�
217)
Wom
enre
crui
ted
from
2Tu
cson
clin
ics,
mea
nag
e57
.2y,
75%
Hisp
anic
,in
com
e$9
737/
y.
Activ
eco
ntro
l—pr
ovid
erco
unse
ling
(AC-
PC):
Atea
chcl
inic
visi
t,NP
spr
ovid
edhe
alth
educ
atio
nbr
ochu
res,
disc
usse
dbe
nefit
san
dba
rrie
rsto
incr
easi
ngPA
and
F/V,
gave
beha
vior
chan
gepr
escr
iptio
n;su
gges
ted
goal
s15
0�m
in/w
kof
PAan
d5�
serv
ings
F/V
per
day.
Prov
ider
coun
selin
g�he
alth
edcl
asse
s(P
C�HE
):Co
unse
ling
plus
subj
ects
refe
rred
to2
educ
atio
ncl
asse
son
diet
and
PA;
also
am
onth
lyhe
alth
new
slet
ter
for
12m
o.Pr
ovid
erco
unse
ling�
heal
thed
ucat
ion
clas
ses�
CHW
prov
ided
soci
alsu
ppor
t(P
C�HE
�CH
W):
Coun
selin
gan
dhe
alth
educ
atio
ncl
asse
spl
ussu
bjec
tsre
ceiv
edse
miw
eekl
yto
mon
thly
tele
phon
eca
llsfro
mCH
Ws
topr
ovid
ein
fore
gard
ing
bene
fits
ofPA
and
F/V,
how
tom
odify
beha
vior
,bi
mon
thly
wal
kspr
ovid
eden
cour
agem
ent
tofin
dw
alki
ngpa
rtner
san
dsu
ppor
t.
F/V:
Chan
geat
12m
o,PC
�HE
�CH
W:
�0.
26�
�0.
5,1.
0vs
PC�
HE�
0.23
��
1.0,
0.5
vsPC
�0.
59�
�1.
2,0.
1,NS
Dal
lcom
paris
ons.
�7.
4%m
ore
wom
enw
hore
ceiv
edPC
�HE
�CH
Wpr
ogre
ssed
toea
ting
�5
F/V/
dth
anin
PC�
HE(�
8.3%
)or
PC(�
5.2%
),P�
0.05
,ES
�0.
07.
PAm
in/w
k:Ch
ange
from
base
line,
PC�
HE�
CHW
:�
22.8
(6.0
,39
.6),
P��
0.01
,vs
PC�
HE:
�22
.6(2
.2,
43.0
),P�
0.05
,vs
PC:
�15
.1(0
.5,
29.8
),P�
0.01
,ES
�0.
03.
BMI:
Chan
gefro
mba
selin
e,PC
�HE
�CH
W:
0.1
(�0.
3,0.
6)vs
PC�
HE:
�0.
7(�
0.1,
1.4)
vsPC
:�
0.1
(�0.
6,0.
5),
NSD
allc
ompa
rison
s.
Tota
lcho
lest
erol
(mg/
dL):
Chan
gefro
mba
selin
e,PC
�HE
�CH
W:
�8.
3(�
16.0
,�
0.7)
vsPC
�HE
:�
10.9
(�19
.9,
�1.
8)P�
0.05
vsPC
:�
6.1
(�13
.7,
1.4)
.SB
P(m
mHg
):PC
�HE
�CH
W:
�5.
1(�
8.9,
�1.
2)P�
0.01
NSD
inot
her
2gr
oups
.DB
P(m
mHg
):PC
�HE
�CH
W:
�1.
3(�
0.8,
3.3)
vsPC
�HE
.43
(�1.
6,2.
5)vs
PC�
3.4
(1.5
,5.
2).
(Con
tinue
d)
422 Circulation July 27, 2010
Tabl
e3.
Cont
inue
d
Refe
renc
e(s)
,Ye
ar,
Stud
yDe
sign
/Du
ratio
n(N
)Po
pula
tion/
Sam
ple
Inte
rven
tion
Outc
omes
Calo
ries/
Fat/F
ruits
and
Vege
tabl
es/F
iber
/Sod
ium
PAW
eigh
tBP
/Cho
lest
erol
/Glu
cose
/He
mog
lobi
nA1
c
Stod
dard
etal
,112
2004
,M
AW
ISEW
OMAN
Proj
ect,
2-gr
oup
RCT/
12m
o(N
�14
43)
Wom
en,
mea
nag
e58
y,79
%bl
ack,
70%
with
BMI�
25,
all
unin
sure
dor
unde
rinsu
red,
rete
ntio
n:80
%fo
rEI
,73
%fo
rM
I.
Allp
artic
ipan
tsre
ceiv
edlo
w-li
tera
cyfa
ctsh
eets
onCV
Dris
ks,
nutri
tion,
and
PA;
also
afo
llow
-up
scre
enin
gat
12m
o.M
inim
umIn
terv
entio
n(M
I):Su
bjec
tsre
ceiv
edco
mpr
ehen
sive
CVD
risk
asse
ssm
ent,
on-s
iteco
unse
ling,
educ
atio
n,re
ferr
al,
and
follo
w-u
pas
need
ed.
Enha
nced
Inte
rven
tion
(EI):
Subj
ects
rece
ived
sam
eas
MIp
lus
grou
ped
ucat
ion,
one-
on-o
nedi
etar
yan
dPA
coun
selin
g,gr
oup
activ
ities
such
asw
alki
ng.
F/V:
80%
MIv
s82
%EI
�5
serv
ings
/d,
P�0.
12.
Prop
ortio
nw
ithin
crea
sed
PA:
6%M
Ivs
18%
EI,
P�0.
04.
…Pr
opor
tion
with
norm
alBP
:73
%M
Ivs
82%
EI,
P�0.
80;
norm
alto
talc
hole
ster
ol:
74.6
%in
MIv
s81
%in
EI,
P�0.
63.
Yanc
eyet
al,59
2006
,2-
grou
pRC
T/2-
,6-
,an
d12
-mo
(N�
366)
Obes
ebl
ack
wom
enat
tend
ing
abl
ack-
owne
dgy
m.
Mea
nag
e45
.5y,
inco
me
$40
000–
$59
000/
y.
A1-
ygy
mm
embe
rshi
pw
asof
fere
dto
allp
artic
ipan
tsas
anin
cent
ive
topa
rtici
pate
inst
udy.
I:Su
bjec
tspa
rtici
pate
din
8w
eekl
y2-
hin
tera
ctiv
egr
oup
sess
ions
incl
udin
gPA
and
diet
ary
educ
atio
npr
omot
ing
low
-fat
com
plex
CHO
rich
diet
;pe
dom
eter
san
dex
erci
seba
nds
prov
ided
;di
etar
yre
calls
done
bydi
etiti
an3
or4
times
,pr
ovid
edfe
edba
ck.
Topr
ovid
eso
cial
supp
ort,
subj
ects
invi
ted
toco
me
togy
mw
itha
frien
d.In
stru
ctor
sw
ere
cultu
rally
/et
hnic
ally
mat
ched
tosu
bjec
ts.
C:Su
bjec
tsre
ceiv
ed8
wee
kly,
2-h
inte
ract
ive
sess
ions
onbl
ack
wom
en’s
heal
thto
pics
with
out
the
soci
alsu
ppor
tco
mpo
nent
.
…Fi
tnes
s,w
ithin
grou
p:Ig
roup
and
Cgr
oup
fitne
ssle
vels
(per
1-m
ileru
n/w
alk)
impr
oved
by1.
9an
d2.
3m
in,
resp
ectiv
ely
at12
mo.
With
ingr
oup
diffe
renc
es,
P�0.
0001
for
both
Iand
C;NS
Dbe
twee
ngr
oups
.
Wei
ght
(kg)
:Bo
thgr
oups
sign
ifica
ntly
heav
ier
at12
mo,
P�0.
001.
…
Yane
ket
al,55
2001
,2-
grou
pcl
uste
rRC
T/1
y(N
�52
9)
Allb
lack
wom
en,
mea
nag
e53
y,In
com
e�
$36
000/
y.No
te:
Ultim
atel
yth
est
anda
rdan
dsp
iritu
alin
terv
entio
nsop
erat
edid
entic
ally
(SI)
sinc
ew
omen
did
not
belie
veth
ere
coul
dbe
ach
urch
-bas
edpr
ogra
mw
ithou
tsp
iritu
ality
.St
anda
rdbe
havi
oral
inte
rven
tion
(SBI
):Su
bjec
tsat
tend
edki
ck-o
ffre
treat
for
1.5
days
,re
ceiv
edfe
edba
ckon
base
line
data
;al
sore
ceiv
ed20
wee
kly
grou
pse
ssio
nson
diet
and
PAfo
cusi
ngon
build
ing
self-
effic
acy
and
skill
s;ea
chse
ssio
nin
clud
edw
eigh
-ins,
tast
ete
sts,
cook
ing
dem
os,
and
30m
inof
mod
erat
e-in
tens
ityPA
.Af
ter
20w
ks,
lay-
led
wee
kly
sess
ions
prov
ided
info
/sup
port
for
rest
ofye
ar.
Chur
chsp
onso
red
year
lyev
ents
.Sp
iritu
alIn
terv
entio
n:W
eekl
yse
ssio
nsin
clud
edpr
ayer
and
heal
thm
essa
ges
enric
hed
with
scrip
ture
,ae
robi
csto
gosp
elm
usic
,or
prai
sean
dw
orsh
ipda
nce.
Self-
help
cont
roli
nter
vent
ion
(SH)
:Su
bjec
tsre
ceiv
edAH
Am
ater
ials
onhe
alth
yea
ting
and
PAan
din
form
atio
nta
rget
edto
subj
ects
’pe
rson
alsc
reen
ing
resu
lts.
Ener
gyin
take
(kca
l/d):
Chan
geat
1y,
�11
7fo
rSI
vs�
7fo
rSH
.W
ithin
grou
pP�
0.00
01fo
rSI
vsP�
0.81
90fo
rSH
.Be
twee
ngr
oup
P�0.
004.
Na(m
g/d)
:�
145
inSI
vs�
8SH
,w
ithin
grou
pP�
0.00
01an
dbe
twee
ngr
oup
P�0.
02.
Tota
lfat
(g/d
):Ch
ange
at1
y,�
8.1
inSI
vs�
2.3
inSI
,w
ithin
grou
pP�
0.00
01fo
rSI
and
0.23
74fo
rSH
,Bt
wgr
oup
P�0.
03.
…W
eigh
tlo
ss(lb
):Ch
ange
at1
y,�
1.1
SIvs
�0.
83in
SH,
w/g
roup
P�0.
009
betw
een
grou
pP�
0.00
08.
BP(m
mHg
):Ch
ange
at1
y,SB
P�
1.6
and
DBP
�0.
36in
SIvs
SBP
�0.
95an
dDB
P�
0.22
inSH
;w
ithin
grou
pP�
0.00
4fo
rSB
Pan
d0.
21fo
rDB
Pin
SI;
NSfo
rSH
;NS
Dbe
twee
ngr
oups
.
WIC
indi
cate
sW
omen
,In
fant
s,an
dCh
ildre
n;NP
,nu
rse
prac
titio
ner;
and
CHO,
carb
ohyd
rate
s.
Artinian et al Promoting Physical Activity and Dietary Changes 423
group differences for the majority of studies was small, rangingfrom 0.00 to 0.33, except for the preliminary study of Carels etal,15 that used motivational interviewing to augment behavioralintervention and reported an ES of 0.84.
Cognitive-Behavioral Strategies for PromotingBehavior ChangeCognitive-behavioral strategies are an essential component ofbehavior change interventions. These strategies focus on chang-ing how an individual thinks about themselves, their behaviors,and surrounding circumstances and how to modify their life-style. As illustrated in Tables 2 and 3, at least 2 or morestrategies were incorporated in studies that yielded favorableoutcomes.
Goal SettingSeveral lines of evidence indicate that setting goals at the outsetof the program is important to achieve the desired behaviorchange. Under most circumstances, setting specific goals leadsto higher performance compared with no goals or vague goals.16
Compared with individuals who have vague or absent goals,individuals who target a specific behavior change are morelikely to be successful.17,18 Such goals may vary by degree ofdifficulty, specificity, and complexity; for example, makingsome dietary changes can be complex and requires severalintended outcomes.19 The use of goals is more successful whenthe goals are specific in outcome, proximal in terms of attain-ment, and realistic in terms of the individual’s capability.20 Goalsthat focus on behavior (eg, increasing whole grain intake) ratherthan a physiological target (eg, improving low-density lipopro-tein [LDL] cholesterol or glucose levels) are preferable becausebehaviors are under a person’s more direct control and alsoobservable by the individual, whereas several factors (eg, genet-ics) can influence physiological targets.16,19,21,22
Setting appropriately ambitious goals is also important. Goalsthat are too difficult may not be attempted, whereas those viewedas too easy may not be taken seriously or provide a sense ofsatisfaction once achieved. Providing regular feedback on goalattainment is important to instill a sense of learning and mas-tery.16 Of the 74 trials described in Tables 2 and 3, 31 trials(42%) included goal-based diet and/or PA strategies.23–53 Posi-tive dietary or PA behavior changes were observed in all but235,46 of the trials. Goals either set by participants43,44,46,48,54 orassigned by the healthcare provider can lead to desired outcomes(eg, weight loss).26,38,53,55
Self-MonitoringThe purpose of self-monitoring is to increase one’s awarenessof physical cues and/or behaviors and to identify the barriersto changing a behavior. Self-monitoring facilitates recogni-tion of progress made toward the identified goal (eg, minutesof PA or number of calories consumed per day), thusproviding direct feedback. Self-based monitoring allows theindividual to assess progress with the program on his/herterms, removing barriers such as travel or scheduling con-straints associated with structured group programs. Self-monitoring interventions can be simple, such as pencil-and-paper logs of PA or dietary intake or charting of weight lost, stepstaken, or distance walked.23,26,27,29,35,36,38,40,42,46,50–52,56–59 Self-monitoring strategies can be provided and then left to the
discretion of the individual or applied in conjunction withexternal prompts incorporated into the behavior-change strat-egy. For example, such prompts can include scripted tele-phone messages or Internet e-mail reminders, specializedpersonal digital assistant (PDA) programs for monitoringdietary intake and PA, as well as both commercial andfree-of-charge Internet-based programs.35,36,57 Studies to datesuggest that electronic self-monitoring systems can be effec-tive for monitoring behavior changes. An advantage ofelectronic monitoring systems is their mobility, decreasingcost, and increasing availability; a potential limitation is theabsence of human interaction.
Both observational data60–64 and evidence from clinical tri-als26 –28,30,36,38,50,52 demonstrate the importance of self-monitoring in achieving behavior change. A recent meta-analy-sis found that PA intervention studies using self-monitoringdemonstrated larger effect sizes than studies without self-monitoring.65 In a recent trial of weight loss, participants whoself-monitored their food intake lost twice as much weight asthose who did not self-monitor.62 Frequency of self-monitoring,as well as detail and proximity in time to the recorded behavior,can influence efficacy of self-monitoring.62 In a study testinginterventions to promote weight loss, individuals in a combinedtherapy group who frequently recorded their weight achievedmore than twice the weight loss than those who recorded theirweight infrequently.28 In the Women’s Health Initiative DietaryModification Trial, a randomized controlled trial in nearly50 000 postmenopausal women, independent predictors of di-etary change at 1 year included younger age, more education,having a more optimistic personality, attending more interven-tion sessions, and submitting more self-monitoring records.64
Notably, at 3 years, the only predictors of continued dietarymaintenance were attending more sessions and submitting moreself-monitoring records.63,64 Among the 25 trials with sizableminority representation in Table 3, only 6 included interventionsthat described self-monitoring.42,46,50–52,59 Five of these 6 trialsthat included self-monitoring42,46,50–52 led to positive lifestylebehavior changes, compared with 13 of the 19 trials that didnot include self-monitoring. Thus, both in whites and minor-ity populations, self-monitoring appears to be an effectivecomplement to behavioral intervention strategies.
Frequent and Prolonged ContactCompared with single-session interventions, the evidencesuggests that programs that incorporate scheduled follow-upsessions as a core component are generally more effec-tive.25,26,28,41,43,47,52,55,66–69 Frequent contact with individualshelps establish trust between the provider and individual, acomponent of care especially important among racial/ethnicminority groups.70 Ongoing contacts can be delivered by variousmodes, including face-to-face, telephone, email or through theInternet.27,36,68,69,71 When combined with the use of group-basedinterventions, scheduled follow-up sessions provide several ad-vantages, including social support from the peer group, anincreased desire to succeed due to a sense of commitment to thegroup, and an opportunity to modify the program based onfeedback from group members or the program leaders.
Across all behavioral domains, it is well-established thatadherence to any new behavior will often decline as the
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intervention is reduced or withdrawn. Evidence suggests thatas the frequency of contact decreases, achievement of initialbehavior change also decreases.72 Further, any alreadyachieved behavior change often diminishes over time asfrequency of the follow-up decreases, and particularly sowhen the intervention ceases entirely.41,59,68 Greater numbersand more prolonged time courses of follow-up sessionsfacilitate success across sequential stages of behavior change,such as new learning of diet and/or PA behavior changeskills, practicing of these skills, problem solving and findingsolutions to overcome relapse, integrating new diet and PAbehavioral skills into one’s daily routine, and learning skillsto facilitate maintenance of new behaviors.73 Among the trialsreviewed (Tables 2 and 3), the majority of interventions thatled to dietary or PA changes that lasted �12 months includedfollow-up contacts over at least 4 months.26,38,46,48,51,53,55,74–76
There are few data on critical time points for follow-up.Expert opinion suggests that 6 months is a critical time to assessmaintenance, but no data are available that compare this periodwith others between 3 and 12 months. Initial intervention andfollow-up should be early and often, incorporating the expecta-tion of self-monitoring and deliberate follow-up. In the absenceof conclusive data, expert opinion suggests that follow-upbeyond the initial visit could include visits at 6 weeks; then at 3,6, 9, and 12 months; and then every 6 months thereafter ifbehavior change adherence is successful. Lack of adherenceshould prompt more frequent follow-up, whether in person, bytelephone, or electronically. Further research is needed to con-firm the feasibility and effectiveness of this suggested timeframe versus other alternatives.
Feedback and ReinforcementHealthcare provider feedback helps individuals learn newdietary or PA behavioral skills by providing an externalmeasuring stick against which to assess their progress.77
Feedback about behavior performance can illuminate conse-quences of diet and PA behavior for an individual, which maymotivate individuals to continue a certain behavior or providedirection for adjusting behavior to reach a targeted goal.78
When goal setting is combined with receipt of performancefeedback, individuals can use information about their currentlevel of performance to set realistic goals for improvement.78
Evidence in Table 2 suggests that feedback is frequentlyincluded in successful behavior change interven-tions.24,27,29,30,32,33,36,44,46,52,55,57,69,71,79–81 Six of the 25 trialslisted in Table 3 described provision of feedback as part of theintervention. Five of these studies resulted in positive lifestylechanges.44,46,52,55,81 Of the successful trials, all interventionsincluded provision of feedback about the initial baselinescreening results, and several included further feedbackduring follow-up assessments. Feedback based on initialscreening can help individuals become aware of the need forbehavior change, and feedback during follow-up providesupdated information about ongoing behavior change efforts.
Self-Efficacy EnhancementSelf-efficacy, a component of social cognitive theory, describesan individual’s perception regarding his/her abilities to carry outactions necessary to perform certain behaviors (eg, makingchanges in diet or lifestyle).20 Perceived self-efficacy is a major
determinant of performance independent of an individual’sactual underlying skill.20 The strength of perceived self-efficacyis particularly important, as individuals are more likely to bothinitiate a behavior and continue their efforts until success isachieved if their perceived self-efficacy is higher.20 Thus en-hancement of an individual’s perceived self-efficacy can beincorporated into interventions to improve the likelihood ofsuccessful behavior change. Bandura’s theory suggests 4 sourcesof self-efficacy that can be drawn on and incorporated intointervention strategies to enhance self-efficacy.82 The sourcewith the greatest potential for increasing self-efficacy, masteryexperiences, entails having a person successfully achieve a goalthat is reasonable and proximal; for example, substituting fruitfor a high-calorie dessert or being able to walk 1 mile. A secondsource, vicarious experience, consists of the individual witness-ing someone who is similar in capability successfully performthe desired task; for example, observing patients exercise andimprove their physical function in cardiac rehabilitation orwatching a nonprofessional prepare a healthy meal. A thirdsource, verbal persuasion, entails the provider persuading theperson that he/she believes in the person’s capability to performthe task. This is the weakest source for improving self-efficacy,but can be implemented via telephone or other electronic modes.The fourth source, physiological feedback, entails interpreting tothe individual the meaning of different symptoms associatedwith behavior change. Examples include explaining that expe-riencing fewer symptoms with exertion is related to regularparticipation in a physical activity program or that feeling lessfatigued or more comfortable is related to weight loss.20 Anextensive body of evidence indicates that self-efficacy influencesbehavior change across all the behavior domains related to CVDrisk reduction.83–92 Self-efficacy enhancements were incorpo-rated into the interventions of several of the studies that yieldedfavorable outcomes.30,39,40,46,54,55,68,79,93
IncentivesThe efficacy of incentive programs to induce or support behav-ioral change has been most extensively studied at the workplace.The most commonly used incentives have been financial, suchas health premium reductions or direct cash payments/bonusesfor specific changes.94 Few interventions described in thisreview included incentives,34,57,76 and the return on investmentfrom them has not been widely assessed. Novel but untestedincentive strategies include rewards for employees frequentlyparking in the spaces located furthest away from the work site inthe company parking lot or lowering the charge for use of on-sitefitness facilities when frequency of use is higher.
ModelingModeling is a behavior change strategy that consists ofhaving the person observe another individual perform behav-iors (eg, engaging in PA or preparing healthy food) that arerelated to his/her goal. Among interventions described inTables 2 and 3, several incorporated modeling, including useof in-person or video cooking demonstrations and personalPA training (having credible individuals demonstrate how toexercise and have the individual practice with them ifpossible).25,43,54,55,75,95,96 Another modeling approach is tohave a person speak with someone who has been successfulin making behavior changes (eg, maintained weight loss or a
Artinian et al Promoting Physical Activity and Dietary Changes 425
PA program). Exposure to models that are credible toparticipants can be an effective strategy to enhance skills forchanging behavior and enhancing self-efficacy.82
Problem SolvingProblem solving consists of 5 steps: identifying and definingthe problem, brainstorming solutions, evaluating the pros andcons of potential solutions, implementing the solution plan, andevaluating its success.97 Problem solving can be used to help anindividual navigate barriers to behavior change (eg, negotiatingsupport from the family when attempting dietary change). It isimportant to have the individual do the brainstorming whendeveloping solutions and, when possible, to have the personpractice the skill.97 Tables 2 and 3 describe several studies thatincluded problem solving as a part of interventions that led topositive behavior change.31,32,39,41,43–45
Relapse PreventionRelapse prevention is an approach that makes a person awarethat it is normal to deviate episodically from the goal behavior,such as missing some scheduled exercise sessions or giving upon the program due to lapses. Individuals are taught to recognizepast situations that have placed them at risk for lapses from theirdietary or PA behavior change program (eg, vacations orcalendar holidays) and how to use behavioral and cognitivestrategies for handling these situations.30 Although few inter-ventions reviewed specifically addressed relapse preventionas a strategy,23,30,45 others may have indirectly addressedrelapse prevention through the inclusion of social sup-port,29,35,41,47,53,55,76,80 through problem solving to reducebarriers,31,32,39,41,44 or through a reinforcement program.98
Motivational InterviewingMotivational interviewing is a directive, individual-centeredcounseling style for eliciting behavior change with a centralpurpose of helping individuals to explore and resolve theirambivalence (ie, lack of readiness toward changing their behav-ior).99 Briefly, the 7 key principles that characterize the nature ofmotivational interviewing include the following: (1) motivationto change is elicited from the individual, rather than imposedfrom without; (2) it is the person’s task, not the counselor’s, toarticulate and resolve his or her ambivalence; (3) direct persua-sion is not an effective method for resolving ambivalence100,101;(4) the counseling style is generally a quiet and eliciting one; (5)the counselor is directive in helping the person to examine andresolve ambivalence; (6) readiness to change is not a person trait,but a fluctuating product of interpersonal interaction; and (7) thetherapeutic relationship is more like a partnership than one inwhich there are expert/recipient roles.100
Interventionist behaviors that are characteristic of motiva-tional interviewing include seeking to understand the per-son’s frame of reference, particularly via reflective listening,and expressing acceptance and affirmation; eliciting andselectively reinforcing the person’s own self-motivationalstatements, expressions of problem recognition, concern,desire and intention to change, and ability to change; moni-toring the person’s degree of readiness to change; ensuringthat resistance is not generated by jumping ahead of theindividual; and affirming the person’s freedom of choice andself-direction. Training and certification of the interventionist
is necessary to achieve optimal results. There are several printand electronic resources to help clinicians wanting to learnmore about motivational interviewing,101 including the fol-lowing Web site: http://www.motivationalinterview.org/training/trainers.html. Referral to allied professionals trainedin motivational interviewing is also an excellent option forindividuals ambivalent about behavior change.
Evidence suggests that motivational interviewing can facili-tate behavior change. A 2003 meta-analysis19 was conducted oncontrolled clinical trials investigating interventions that primarilyimplemented motivational interviewing principles. Four studiesdemonstrated a combined ES of 0.53 (95% CI, 0.32 to 0.74) fordiet and exercise, thereby indicating moderate efficacy. Addi-tional motivational interviewing studies reported increased fruitand vegetable consumption as part of general lifestyle change inwhites and blacks,32,102,103 firefighters,71 smokers,93 and collegestudents.104 Other studies demonstrated that motivational inter-viewing increased PA among women and/or individuals withdiabetes or obesity15,40,105 and black individuals with hyperten-sion.106 An array of studies have reported improved bodymass index or weight loss using motivational interviewing inworkers in Oregon,107 other occupational settings,105 blackindividuals with hypertension,106 and white females.15 Over-all, there is general consensus that motivational interviewingoffers an evidence-based approach for enhancing adherenceto behavioral interventions, including dietary and PA change.
Intervention Processes or Delivery Strategies
Targeting Single Behaviors Versus Multiple BehaviorsEvidence described in Tables 2 and 3 shows that inter-ventions may focus on changing only PA,34,46,69,108,109
only dietary behaviors,17,24,30,32,33,39,47,48,54,68,74–76,80,81,96,110 orboth.26–29,35,36,38,43,44,50,51,53,55,57,66,67,111–113 Studies that focuson multiple behaviors have generally applied the same type ofintervention strategy (eg, provision of education materials,counseling sessions, follow-up monitoring) to change eachspecific behavior. Results of these studies have been variable.Most reported positive results (ie, the desired change in bothPA and dietary behaviors). However, studies have not con-sistently resulted in improvements in related metabolic/vascular biomarkers (eg, serum lipids, blood pressure). Theresults of a meta-analysis of studies testing interventions toincrease PA among older adults indicated that interventionstargeting only PA resulted in higher ES than studies designedto change multiple health behaviors.65
There is limited knowledge about the relative benefits ofsimultaneous versus sequential delivery of multiple PA anddietary behavior change interventions in adults. In a randomizedtrial of 289 blacks with hypertension, participants were random-ized to 1 of 3 groups: (1) an in-clinic counseling session every 6months on smoking, reduced dietary salt intake, and PA,supplemented by use of motivational interviewing strategies bytelephone for 18 months; (2) a similar protocol that introduced 1behavior every 6 months; or (3) a 1-time referral to existinggroup classes.106 When examining individual target behaviors at6 months, 29.6% in the simultaneous, 16.5% in the sequential,and 13.4% in the usual care arms had reached the urine sodiumgoal (P�0.01 for the simultaneous versus the usual care groupand P�0.05 for the simultaneous versus the sequential group).
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At 18 months, 20.3% in the simultaneous, 16.9% in the sequen-tial, and 10.1% in the usual care arms were negative for urinarycotinine (P�0.06 for the simultaneous group versus the usualcare group and P�0.08 for the overall trend in smokingcessation), whereas 6.5% in the simultaneous arm, 5.2% in thesequential arm, and 6.5% in the usual care arm were adherent to�2 target behaviors (all statistical contrasts resulted in P�0.05).In contrast, findings from another trial among 315 femalesmokers supported a sequential over simultaneous approach tomultiple behavior changes, including diet, exercise, and smokingcessation.114
It is worth noting that additional studies published later thanour time window or performed outside the United States havealso shown mixed results for superiority of sequential versussimultaneous intervention strategies.115,116 In 1 trial, at 6 months,the simultaneous strategy was superior for a fat intake interven-tion and for a subgroup of participants who did not meet physicalactivity recommendations at baseline.115 However, the sequen-tial intervention resulted in better maintenance of interventioneffects at 2 years.117 Thus, the relative merits of simultaneousversus sequential intervention are unresolved, and more studiescomparing these intervention modes are needed.
Print- or Media-Only Delivery StrategiesMedia messages, printed materials, and other nonindividualizedstrategies may be used to provide information to individuals toencourage PA and dietary change. In a study involving individ-uals with mild hypertension, the use of nonindividualized edu-cational mailers did not significantly decrease BP.118 Overall,self-help approaches that provide nonindividualized brochuresand other behavioral learning tools without any additionalpersonal counseling appear to produce little benefit.55
In contrast, in a study comparing the efficacy of nonindividu-alized self-help manuals versus motivationally matched reportsand manuals to promote PA adoption, both groups showedsignificant improvement in PA at 6 months, but the increase was50% greater among participants receiving motivationallymatched materials.79 The mode of delivery may also influenceefficacy. In a study comparing the effects of motivationallymatched print materials versus motivationally matched tele-phone counseling, both groups had significantly increased PA at6 months, but participants receiving the print materials weremore likely to maintain PA change at 12 months.69 Thus,whereas further research on optimal modes of delivery isneeded, the evidence suggests that individualized print or mediamaterial are more effective than nonindividualized ones.
Group, Individual, Technology, andMulticomponent-Based Delivery StrategiesFour general approaches can characterize interventions to mod-ify dietary intake and increase PA, including (1) group-basedinterventions, (2) individual-based interventions, (3) computer/technology-based (interactive session, personal or automatedtelephone calls) interventions, and (4) multicomponentinterventions.
Group-Based InterventionsGroup-based interventions are characterized by opportunitiesfor social interaction, support from others who are experienc-ing similar challenges in modifying their lifestyle, role
modeling, and positive observational learning.29 Group-basedapproaches are commonly used in randomized clinical trialsemploying standard behavioral interventions for weightloss,24,25,28,29,66,72,109 as well as in other trials using diet andPA changes to target CVD risk factors such as BP or bloodcholesterol.23,26,27,56,66,67,113 In a meta-analysis of studies thattested interventions to increase PA among older adults,group-based intervention delivery resulted in larger ES thanindividual-based interventions.65
Group-based interventions have been successful in bothwhite28 and minority populations.76 The majority of studies withminority populations (18/25) included group-based interventionstrategies.42,43,46–48,51–55,59,74–76,96,110,112 Minority populationsranged from being 100% black,42,43,51,55,75,76,102,103,119 73% to100% Hispanic,44,46,52,53,110 to smaller subsamples of blacksand/or Hispanics.26,45,47,48,50,54,74,93,96,112,113
Typically, group interventions are administered in a small,closed group format (eg, 7 to 10 members). Groups initially meetas often as weekly, with meeting frequency often decreasingover time.28,43 Sessions may be led by a lay person or aprofessional.43,46,56,58,76,113 Successful group-based interventionsincorporate didactic education, counseling strategies, and multi-ple behavior change strategies such as goal setting and self-monitoring.26,38 Some group-based programs have includedskill-building sessions such as food label reading; groceryshopping; methods for healthy cooking; practice using pedom-eters, exercise bands, or other exercise equipment; and walkinggroups.24,68 Of the trials in Table 3 with a group-based interven-tion delivery, approximately one third (n�9) incorporated theuse of skill-building strategies.43,46,47,54,55,59,74,76,112 Among these,all but 1 study46 demonstrated at least within-group positive changesin dietary or PA behaviors or improved CVD risk factors.
In group-based weight loss interventions, the greatestweight loss usually occurs within the first 6 months of thestudy.15,30,120 Regardless of type of diet or activity, investi-gators typically report that many individuals find it challeng-ing to maintain the reduced caloric intake and/or PA plan, andweight is often regained by many individuals as early as 4 to6 months into the program. A major challenge in weightmanagement is identifying strategies to assist individuals inmaintaining long-term weight loss.24,121 To achieve this,investigators have tried supplementing the group-based ap-proach by recruiting participants with friends and enhancingsocial support,29 providing home exercise equipment,109 us-ing aerobic or strength-training exercises,72 providing im-proved access to counselors through the Internet,36,57,122 andusing a stepped-care approach and motivational interviewingfor those who did not meet their weight loss goals.15 Thestudies found improvements in all groups, with smallbetween-group differences in energy and fat consumption orPA changes, suggesting that supplementary strategies to mostbasic group-based approaches do not have a major effect onefficacy; however, most approaches that include the basicelements of standard behavioral treatment will have a positiveeffect on eating and PA habits and will result in weight loss,at least for the short term.
Commercial programs that use the group approach and aself-monitoring system to guide food restrictions (eg, WeightWatchers) appear to be more effective than self-help approaches.
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For example, in a trial among 212 adults,123,124 greater weightreductions were observed at both 1 and 2 years in the commer-cial group compared with the self-help group, with accompany-ing improvements in BP, blood lipids, insulin, and glucoselevels. Although such commercial programs have many similar-ities to the empirically tested noncommercial ones describedabove, having access to continued group support and ongoingcontact for 2 years may be the salient features of these programscompared with a self-help approach. However, due to their cost,commercial programs may be less available to socioeconomi-cally disadvantaged populations.
Individual-Focused InterventionsIndividual-focused interventions allow tailoring or personal-ization of healthcare recommendations to the learner’s par-ticular health concerns and life context. Individualized coun-seling has been effectively provided by health educatorsand/or counselors,31,32,125 physicians,95 and/or other health-care professionals.30 A meta-analysis of randomized clinicaltrials testing interventions to promote PA among older adultsfound that individualized interventions consisting of a healthrisk appraisal, activity counseling, and/or cognitive-behavioral strategies resulted in increased PA levels for atleast short term (�1 year), compared with a control group.126
A wide range of individual-based strategies have beentested, including in-person, telephone, electronic, and com-bined approaches. For example, among the studies reviewed,individual-only approaches included 6 biweekly telephonesessions,30 3 monthly telephone sessions,31 one 8-minutephysician-provided counseling session during a clinic visit,95
three 30- to 45-minute face-to-face counseling sessions fol-lowed by 12 counseling telephone calls,125 and 2 face-to-face45-minute counseling sessions followed by two 5- to 10-minute telephone calls 3 and 6 weeks after the sessions.32
Combined individual-based approaches appear to be suc-cessful in creating behavior change. For example, the use ofpersonal goal setting and self-monitoring via individualtelephone counseling improved adherence to a cholesterol-lowering diet and reduced serum cholesterol compared withusual care.30 In another trial, supplementing clinician advicewith telephone counseling by a health educator was moreeffective in improving levels of PA than clinician advicealone.125 In a study comparing physician-delivered nutritioncounseling alone versus physician counseling combined within-office prompts to usual care,95 only the combined programdecreased participants’ saturated fat intake, weight, and LDLcholesterol. The average counseling time was 8.2 minutes,5.5 minutes more than in the control group.95 No studies wereidentified that examined the effects of in-office prompts only,in-office reminders only, or in-office dietary and/or PAassessment tools only on diet and/or PA behavior change;more research is needed in these areas.
Three studies that addressed individual-based CVD riskreduction in the practice setting were published earlier thanour time window of published articles or were performedoutside the United States but warrant mentioning here.127–129
In 1 study, nurses initiated interventions for smoking cessa-tion, exercise, and diet and drug therapies for hyperlipidemiaamong hospitalized individuals who had suffered an acute
myocardial infarction.127 They followed the study partici-pants after hospital discharge by telephone and mail contact.Compared with usual care, the intervention group reportedhigher functional capacity at 6 months and higher smokingcessation rates and lower LDL cholesterol at 12 months.127 Asecond study delivered a 4-year intervention to assist indi-viduals with coronary artery disease in meeting several CVDrisk reduction goals through improving diet and PA, smokingcessation, and drug therapy.128 After an individualized ses-sion with a nurse at baseline, individuals were followed-up bymail and telephone contact and seen every 3 months in theclinic. Compared with usual care, the intervention group hadless progression of coronary atherosclerosis and decreasedhospitalizations for cardiac events.128 This is one of the fewtrials of sufficient size and follow-up duration to demonstratethat PA and dietary changes lead to reductions in clinical endpoints. A third trial, EUROACTION, investigated the effi-cacy of a nurse-coordinated multidisciplinary, family-based(rather than individual-based) preventive cardiology programconducted in 8 European countries for both primary andsecondary prevention.129 Compared with usual care, moreindividuals and their partners in the intervention groupachieved recommended targets for PA and for fruit, vegeta-ble, saturated fat, and oily fish consumption. Central obesitywas also reduced. These findings indicate that a nurse-ledmultidisciplinary team approach, coupled with support andinvolvement of an individual’s partner and family, can yieldsignificant lifestyle improvements and cardiovascular riskfactor reductions.
Because the studies described here utilized interventions thatwere delivered at the individual level, cognitive-behavioralintervention strategies may also have been incorporated andimproved efficacy. For example, some studies incorporatedmotivational interviewing strategies32,93,103,125; some used goalsetting, feedback, and/or self-efficacy enhancement30,79; andothers used readiness to change31,45,69,104,125,130 or problem-solving31,32,44 strategies. Overall, individual-based interventionshave been shown to be successful, at least for the short term (upto 1 year). In studies with minority samples (Table 3), individualintervention approaches to promoting change seem to result insmaller or fewer changes in total diet or PA compared withgroup-only55 or combined individual- and group-based ap-proaches.26,38,47,51 Research has yet to establish when and forwhom individual-only approaches are most appropriate.
Further investigation should better quantify the processes andcomparative effects of specific individual interventions. Keyquestions include whether the type of provider (eg, nurse,physician) influences efficacy; what specific combination ofcognitive, behavioral, and informational strategy is most effective;and what are optimal strategies for including family members.
Computer/Technology-Based InterventionsWith the growth of computer technology and the Internet,health interventions are increasingly delivered online or withthe use of technology. Several advantages of Internet-basedinterventions have been cited,131 including ability to reachmany people with a single posting; easy storage of largeamounts of information; ease of updating information; abilityto provide personalized feedback; cost effectiveness and
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convenience for users; ability to reach people suffering fromisolation or conditions that cause them to feel embarrassed orstigmatized; timeliness of access; user control of the inter-vention; supplier control of the intervention; and ease ofadapting information for specific populations.36,57,108,122,132
Several studies have employed the use of the Internetor computer-based programs to deliver education andcounseling interventions for weight loss and dietarychange.17,33–36,57,108,122,132 (Table 2). Three studies demon-strated that the combination of an Internet program (eg,weekly reporting and graphs of weight, recipes, and weightloss tips) plus E-counseling (eg, automated praise or feed-back) resulted in greater weight loss than use of the Internetprogram alone.36,57,122 Another study found that Internet-onlycounseling was as effective for weight loss at 6 or 12 monthsas Internet-only counseling plus monthly in-person counsel-ing.35 A strategy of interactive, computer-controlled tele-phone systems for educating participants about a healthy dietresulted in some improvements in fruit, fiber, and saturatedfat intake.17 A supermarket kiosk program providing onsitenutrition information also resulted in improvements in fat,fiber, fruit, and vegetable purchases and intake.33
A few US trials have evaluated the efficacy of Internet orcomputer-delivered interventions to increase PA.34,108,132 In 1small trial (N�65), use of a PA Web site and 12 weeklyE-mail tip sheets resulted in increased total minutes ofwalking, but not time spent in moderate PA at 1 and 3months, compared with a control group.34 In a larger andlonger randomized clinical trial, investigators compared amotivationally tailored Internet intervention to motivationallytailored print material and to publicly available PA Internetsites; at 6 and 12 months, there were no significant differ-ences in minutes of PA among the 3 groups.108
Few Internet studies have been conducted among minorityand/or socioeconomically disadvantaged populations. Inves-tigators have reported that low-literacy individuals may havedifficulty accessing information through the Internet becauseof suboptimal searching strategies (eg, use of nonspecificsearch terms), unwillingness to click on links, accessing Websites written at or above the 10th grade reading level, andperceived higher quantity and complexity of the informa-tion.133,134 An understanding of the target population appearsessential to optimize delivery of Internet-based diet and PAbehavior change interventions.
Overall, the results of these trials are mixed, but at least insome scenarios, the use of Web-based and computerizedmaterials appears to improve weight loss and certain dietarybehaviors; fewer studies have evaluated PA. Combinationsof technology-based approaches may be more effectivethan single interventions; for example, the addition ofE-counseling appeared to improve efficacy of Internet-basedprograms for weight loss.35 The use of the Internet can allowhealthcare providers to reach a greater number of sedentaryadults in a cost-effective manner, but several importantquestions remain unanswered, including effectiveness inlow-income and minority samples, utility for increasing PA,long-term sustainability, optimal components of Internetinterventions (eg, number of log-ins, E-mails, online chats)and relative efficacy versus traditional printed material.
Multicomponent Intervention Delivery StrategiesIn contrast to single strategies, most trials have evaluatedmulticomponent interventions (Tables 2 and 3). Multicompo-nent programs include combinations of technology/media; groupor individual-based delivery strategies such as interactivecomputer-based programs plus telephone follow-up and com-munity resource enhancement80; computerized assessment andfeedback plus videotapes, telephone follow-up, or individualcounseling32,39; physician advice plus motivational videotapes,telephone calls, and interactive mail135; group sessions plus individ-ual motivational interviewing15,40; or individual plus group ses-sions.38,41,58,111 In most multicomponent studies, various behav-ioral strategies were also included, including goal setting,self-monitoring, feedback,38–41,46,49–53,55,58,59,80,81,111 socialsupport,49,76 problem solving,39,41 or motivationalinterviewing.15,40,102
Among nonminority populations (Table 2), all 10 multicom-ponent intervention trials reviewed demonstrated positive di-etary and/or PA outcomes. Among the 16 multicomponentintervention trials involving minority populations (Table 3),most 47–53,55,74–76,81,102,112 demonstrated some positive changes ineither dietary and/or PA behavior. The 2 trials of multicompo-nent interventions that did not lead to dietary or PA changes46,59
may have been limited by insufficient duration or lack ofeffective combination of behavior change strategies. The opti-mal combination of behavior change strategies in multicompo-nent interventions has yet to be determined.
As part of a personalized, medical office-based interven-tion focused on dietary self-management for individuals withtype 1 or 2 diabetes, a computerized assessment of potentialdietary barriers was used to immediately generate 2 printedfeedback forms that were provided in combination withpersonalized counseling and other self-help materials.39 Oneyear later, significant decreases were observed in total fatintake and serum cholesterol levels, but not hemoglobin A1clevels. One of the most successful multicomponent studieshas been the Diabetes Prevention Program (DPP).38 The DPPused individual counseling in the intensive lifestyle interven-tion arm of the trial, with goals of 7% weight loss and 150minutes per week of PA.38 Compared with a control groupthat received some group education, participants assigned tothe lifestyle intervention had greater dietary changes, in-creased levels of leisure-time PA, and greater weight loss.Incidence of diabetes and metabolic syndrome were reducedby 58% and 41% in the lifestyle and control groups, respec-tively. Notably, the effects of the intensive lifestyle treatmentdid not differ significantly by sex, race, or ethnicity. TheLook Ahead Trial,111 an ongoing, multicenter randomizedclinical trial of participants with type 2 diabetes mellitus,combined individual and group sessions. At 1 year, the trialreported significantly greater weight loss, improved fitness,and lower mean hemoglobin A1c in the combined groupcompared with those who received diabetes support andeducation through a limited number of group-only meetings.
Special Considerations for Interventions WithMinority and SocioeconomicallyDisadvantaged PopulationsIn the United States, numerous racial and ethnic groups existwith diverse cultural norms, values, attitudes, beliefs, and
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lifestyle patterns. Interventions designed to change dietaryand/or PA behavior in 1 population group may be lesseffective in another group, especially when the population iseducationally or economically disadvantaged or differs incultural health beliefs or practices from the population inwhich the intervention was initially tested. Optimally, meth-ods to design or adapt interventions should be directlyassessed in diverse populations and settings. Relatively fewerstudies (n�25) within the specified time period for thisreview (1997 to 2007) evaluated samples other than whitemiddle- or upper middle-class Americans. The most com-monly studied minorities were blacks and Hispanics. Studiesin Hispanic populations often did not adequately addresslinguistic competency. Although intervention studies havebeen conducted that included Asian American and NativeAmerican populations, in most, numbers were insufficient toconduct ethnic-specific subgroup analyses. Table 3 displaysthe 25 studies that included ethnic minorities or low-incomeparticipants that were reviewed and that provide the basis foradditional discussion about implementing dietary and PAchange interventions in these population subgroups. It isimportant to recognize that additional diversity occurs withinracial/ethnic groups, so that intervention designs shouldconsider the potentially diverse values, beliefs, and socioeco-nomic characteristics within each group.
Setting in Which Healthcare Is DeliveredFor interventions in minority or socially and/or economicallydisadvantaged populations, an important consideration isidentifying a setting to minimize the barriers to access theintervention. Once access is established, Table 3 indicatesthat interventions conducted in work sites, clinics, communi-ties, and churches can lead to improved dietary intake and PAlevels among blacks and/or Hispanics.
Peer/Lay Led Versus Professionally LedResearch suggests that people are more likely to hear andpersonalize messages, and thus to change their attitudes andbehaviors, if they believe the messenger is similar to themand faces the same concerns and pressures.136 It is thereforeimportant to consider when a person may be more likely tobelieve a lay health advisor versus health professionalthought to be an authority figure. Lay health advisors, peereducators, or community health workers are trusted commu-nity members and usually live in the same communities,speak the same language, have similar values and beliefs, andunderstand the cultural context of the minority target popu-lation.137,138 Lay leaders can improve the quantity of messagesabout healthy behavior and tailor messages to the unique needsand culture of the target population.74 The homophily forethnicity (ie, the tendency of individuals to associate and bondwith similar others) is important and may affect whether layadvisors or healthcare professionals are more effective.
Of the 25 trials reviewed (Table 3), 3 tested lay-led group orindividual-level interventions,43,48,74 and 4 tested interventionsthat combined professional and lay educators.52,53,55,76 All thesetrials generally showed some positive changes related to diet andor weight. The trials using both professionals and lay leadersalso further led to positive outcomes in diet,55,76 blood choles-
terol and BP,53,55 PA,53 and hemoglobin A1c at follow-up.52 It isalso important to note that several studies demonstrated thatprofessional-only led interventions can also lead to improveddiet and PA changes in minorities.42,45–47,93,103 Given the well-documented history of discrimination toward minorities inhealthcare settings, and a greater awareness of historical discrim-ination against blacks,70,139–141 expert opinion agrees that pro-vider capacity for trust building, communication skills, andcultural sensitivity are important ingredients of professional-ledinterventions.
Cultural SensitivityCultural sensitivity in health promotion interventions refers todesigning and delivering interventions that are relevant andacceptable within the cultural framework of the target popula-tion.142 Development of culturally sensitive interventions de-pends on knowledge of the history, values, belief systems, andbehaviors of the members of the target minority group. Theability to overcome language barriers faced by non–English-speaking immigrants is also necessary.143 Of the 25 trialsreviewed (Table 3), 18 designed culturally sensitive interven-tions and had mixed results.43–47,52,55,59,74–76,81,93,96,102,103,110,144
In comparison, the results of the trials not including culturallysensitive interventions42,48,49,51,53,54,112 demonstrated within-and/or between-group differences in diet, PA, or related meta-bolic/vascular biomarkers. Thus cultural sensitivity alone is notsufficient and needs to be combined with essential behaviorchange strategies to produce positive outcomes.
Literacy Level SensitivityWithout adequate literacy skills, individuals cannot read health-related materials. When working with persons of lower educa-tional levels, literacy assessment and modification of methodsfor providing health information are useful. Effective strategiesinclude use of audiovisual and interactive multimedia rather thanprint media; use of simple messages with short sentences, 1- or2-syllable words, and large print with lots of space; and nonre-liance on the Internet for provision of information.54,110,145,146
Seven of the 25 studies described in Table 3 used interventionssensitive to literacy levels44,45,47,52,54,74,81; 6 of these44,45,47,52,74,81
resulted in some positive outcomes. The trial with null out-comes54 lacked other intervention components such as specificbehavioral goals, self-monitoring, or feedback that may havelessened the efficacy of the intervention.
Barriers to Behavior ChangeReported barriers to healthy eating among the disadvantagedand/or minority groups include poor dental health, lack ofaccess to quality produce at affordable prices, inability to findethnically preferred fruits and vegetables in local markets,transportation problems, family customs/habits, social andcultural symbolism of certain foods, and low price and easyaccess to snack foods.147–152 Neighborhoods in which lowersocioeconomic status individuals often live may not be condu-cive to exercise due to high traffic, poor lighting, waste sites,infrastructure deterioration, high crime rates,151,153 and lack ofavailability of facilities that enable and promote PA.154,155 Thusassessment of barriers to behavior change should be part ofinterventions targeting these population groups.
430 Circulation July 27, 2010
AcculturationEvidence supports that acculturation of immigrants to theUnited States negatively influences healthy dietary pat-terns.156,157 For example, highly acculturated Hispanics atefewer servings of fruits and vegetables per day comparedwith those not highly acculturated, suggesting that healthcareproviders need to encourage immigrants to retain traditionalhealthful eating patterns. Thus assessment of acculturationmay be helpful in designing and implementing interventionsto improve dietary habits in immigrant groups.
Fostering Initiation and Maintenance ofBehavior ChangeSeveral factors influence the design of optimal interventionsand may influence a person’s ability to adopt and maintainnew lifestyle behaviors. First, various psychological factorsenable individuals to adopt as well as sustain new behaviorslong term. For initiating a behavior, persons’ consideration ofthe anticipated benefits must compare favorably to theircurrent situation, and they need to hold favorable expectan-cies regarding future outcomes.4,158 The decision to maintaina behavior is dependent, at least in part, on whether theachieved outcomes associated with the new behavior patternare sufficiently desirable to sustain the behavior (ie, on theindividual’s perceived satisfaction with the outcomes of thatbehavior change). Most individuals have clear expectationsabout what a new lifestyle will provide; if their experiencesdo not meet those expectations, they will be dissatisfied andless motivated to maintain it, particularly in environmentsthat are frequently not supportive of healthy choices.
Other factors that may influence adoption and maintenanceof new PA or dietary behavior include:
● Age—Evidence suggests that older age per se does notsignificantly reduce the response to PA or dietary interven-tions. Older age may be associated with more healthfuldietary patterns and better adherence, such as higherconsumption of fruits.159–163 In the DPP trial, the greatestrisk reduction in response to the lifestyle intervention wasseen in the oldest age group, suggesting better adherenceand/or efficacy in this group. However, although olderadults on average may have better adherence, some mayhave barriers to overcome to achieve this adherence. Forexample, some older adults may be at particular risk forpoor dietary habits, especially if they live alone and/or havelow incomes. Although younger adults are more likely tocite time as the main constraint to exercise,164 older adultsmost frequently cite poor health, including pain, reducedmobility, and low endurance.165
● Sex—Lower PA levels in women than men are generallyreported.166–168 Women, however, are reported to havebetter eating habits than men.169–174
● Better health status has been associated with greater levelsof PA.175–177
● Obesity, higher body mass index, and smoking are associ-ated with lower PA levels.175,177–179
● Presence of comorbid conditions and depression negativelyimpact adherence to most lifestyle change regimens.180–183
● Deficits in cognitive processing and memory can reduceadherence, particularly for complex regimens.184,185
● Individual differences in perception and assessment of costsand benefits of behavior change, when different from providerexpectations, may alter responsiveness to interventions.186
● Conscientiousness and self-efficacy each have been re-ported to favorably impact adherence.187
● Somatic factors related to side effects negatively impactadherence to most regimens.180,181,188
● Availability of social support positively influences PA andhealthy food choices.29,189–192
● It is important to consider the above-listed factors as wellas the knowledge levels and skills of the individual beforeimplementing therapeutic lifestyle changes.
RecommendationsTable 4 provides evidence-based and expert opinion recom-mendations on designing and implementing PA and dietaryinterventions in adults. Recommendations are organized toaid clinicians: to use cognitive-behavioral strategies to assistadults to adopt and maintain healthy dietary and PA targets;to make decisions about behavior change intervention pro-cesses and delivery strategies; and to modify interventions foraddressing cultural and social context variables that influencebehavioral change. The level of evidence base for thesedifferent recommendations varies; a few are supported morestrongly by expert opinion or case study rather than directresearch findings. The strength and types of evidence used toderive each recommendation are indicated in Table 4.
Subsequent to May 2007, when the literature review wascompleted for this publication, results from a few landmarkstudies conducted in large study populations were published.These include the POUNDS Lost Study (N�811), which com-pared 4 diets for weight loss, and the 1-year weight loss datafrom the Look AHEAD Study (N�5145).193–195 In each case,weight loss itself, however it was achieved, was associated withreduced CVD risk. In addition to a specified dietary intervention,these studies included behavioral counseling strategies that aredescribed in detail in this article, which were implemented topromote behavior modification for weight loss and to comple-ment the dietary and/or physical activity components of theintervention. Consistent with the recommendations made inTable 4 in the present article, weight loss success was attributedto the best adherence to behavior and dietary recommenda-tions.193–195 The results of these studies add further and consis-tent support for the recommendations made herein that includestate of the art behavior change strategies to counsel individualsin order to promote weight loss as needed along with the dietaryand physical activity changes to maximize reduction in CVD risk.
Implications for Healthcare Policy and forOther Policy
Changes in healthcare policies are needed to make it morefeasible to follow the recommendations made in this state-ment. Providers face numerous barriers to assessment andcounseling for therapeutic lifestyle change. Although a majorprovider barrier to adherence in the acute inpatient setting isa focus on the acuity of the presenting problem, the major
Artinian et al Promoting Physical Activity and Dietary Changes 431
provider barrier in the outpatient ambulatory setting is limitedresources for counseling and sustained follow-up support.196
Across all settings are the persistent and ever-growing issuesof provider time restraints, lack of financial incentives orreimbursement for health promotion, skepticism regardingwhether health promotion counseling will result in behaviorchange, insufficient information about the most effectivecounseling strategies, lack of skills necessary to providepositive individualized counseling using both verbal and non-verbal communication skills, and doubts about the likelihood oflifestyle changes resulting in the desired outcome.197–199 Physi-cians and nurses often cite their own lack of confidence in aperson’s ability to use preventive strategies for long-termbehavior change.200–205
Healthcare delivery systems need to address policy toensure an environment that supports preventive interven-tions.206 Examples of healthcare system policies needed tostrengthen the provider’s ability to promote PA and dietarylifestyle changes include: use of tracking, reporting, andfeedback systems; assessment of practice goals and bench-marks; availability of toolkits containing assessment toolsand diet and PA behavior change guidelines; education andtraining for providers, including cultural sensitivity training;provision of incentives that are tied to desired individual andprovider outcomes; and development of mechanisms forobtaining data on diet and PA behavior before a providervisit. It is encouraging that the American College of Cardi-ology Foundation/AHA’s 2009 performance measures forprimary prevention of CVD in adults include lifestyle coun-seling.207 Performance measures for diet and PA interventionare critical to improve the value placed on these interventionsby the reimbursement system.207
It is important to note that other factors not included in thisreview will affect whether our evidence-informed recommenda-tions are feasible for implementation, will result in improvedlevels of cardiovascular risk factors, and will prevent clinicalevents. Policies that foster individual healthy lifestyle choicesare needed. For example, insurance premiums could be loweredfor those who participate in programs around healthy diet andPA behaviors. Legislative initiatives geared toward providingmore complete and accessible information to the general publicor limiting the use of certain food components in the foodsupply, coupled with guidance on how to use that information orimplement the policy, has been shown to positively influencefood choices and foods available. For example, mandatorycalorie labeling at point of purchase enacted by the New YorkCity Health Department has provided expanded information forindividuals about their food choices.208 This legislatively man-dated regulation has been coupled with large-scale educationinitiatives on how to use the information. An environmentallegislative initiative also championed by New York City is thestaged phase-out of partially hydrogenated fat by food purvey-ors.209,210 Extensive support systems to the food producers toprovide advice and assistance in how to make the change andwhere to obtain the alternate fats were key ingredients in thesuccess of the program. Many other cities have adopted or havelegislative efforts underway to mandate law that food purveyorsphase out industrially produced trans fats. As of October 2009,California passed legislation to limit trans fats, and numerous
Table 4. Recommendations for Counseling Individuals toPromote Dietary and PA Changes to Reduce CardiovascularDisease Risk
Cognitive-behavioral strategies for promoting behavior changeClass I
● Design interventions to target dietary and PA behaviors withspecific, proximal goals goal setting. (Level of evidence: A)
● Provide feedback on progress toward goals. (Level of evidence: A)● Provide strategies for self-monitoring. (Level of evidence: A)● Establish a plan for frequency and duration of follow-up contacts (eg,
in-person, oral, written, electronic) in accordance with individual needsto assess and reinforce progress toward goal achievement. (Level ofevidence: A)
● Utilize motivational interviewing strategies, particularly when anindividual is resistant or ambivalent about dietary and PA behaviorchange. (Level of evidence: A)
● Provide for direct or peer-based long-term support and follow-up, suchas referral to ongoing community-based programs, to offset thecommon occurrence of declining adherence that typically begins at4–6 months in most behavior change programs. (Level of evidence: B)
● Incorporate strategies to build self-efficacy into the intervention.(Level of evidence: A)
● Use a combination of �2 of the above strategies (eg, goal setting,feedback, self-monitoring, follow-up, motivational interviewing,self-efficacy) in an intervention. (Level of evidence: A)
Class II● Use incentives, modeling, and problem solving strategies. (Level of
evidence: B)Intervention processes and/or delivery strategies
Class I● Use individual- or group-based strategies. (Level of evidence: A)● Use individual-oriented sessions to assess where the individual is in
relation to behavior change, to jointly identify the goals for riskreduction or improved cardiovascular health, and to develop apersonalized plan to achieve it. (Level of evidence: A)
● Use group sessions with cognitive-behavioral strategies to teachskills to modify the diet and develop a PA program, to provide rolemodeling and positive observational learning, and to maximize thebenefits of peer support and group problem solving. (Level ofevidence: A)
● For appropriate target populations, use Internet- andcomputer-based programs to target dietary and PA change;evidence is less for targeting PA alone; adding a form ofE-counseling improves outcomes. (Level of evidence: B)
Class IIa● Use individualized rather than nonindividualized print- or media-only
delivery strategies. (Level of evidence: A)Addressing cultural and social context variables that influence behavioralchange
Class IIa● Utilize church, community, work, or clinic settings for delivery of
interventions. (Level of evidence: B)● Use a multiple-component delivery strategy that includes a group
component rather than individual-only or group-only approaches.(Level of evidence: A)
● Use culturally adapted strategies, including use of peer or lay healthadvisors to increase trust; tailor health messages and counselingstrategies to be sensitive to the cultural beliefs, values, language,literacy, and customs of the target population. (Level of evidence: A)
● Use problem solving to address barriers to PA and dietary change,such as lack of access to affordable healthier foods, lack ofresources for PA, transportation barriers, and poor local safety. (Levelof evidence: B)
PA indicates physical activity.
432 Circulation July 27, 2010
other states have similar legislation under review (http://www.ncsl.org/default.aspx?tabid�14362).These types of ap-proaches, if enacted in a collaborative fashion, can serve to shapean environment where optimal lifestyle choices are available andin some cases are the “default” options.
Community environments have been extensively investi-gated in relation to PA and diet.9,211–216 Special efforts bycommunity groups, businesses, and government to increasethe availability of healthier food and PA choices will com-plement provider interventions to implement lifestylechanges. Policies for providing wide and safe routes forwalking and biking in communities and along state andfederal roads, maintaining public parks, reducing exposure tounhealthy fast food or to high-calorie/low-nutrient foods,menu labeling, and increasing access and availability tohealthy foods appear crucial.
Workplace policies designed to engage employees toachieve optimal health, as well as provide opportunities fororganized PA (eg, lunch hour walking programs, instructor-led group exercise) and more healthy eating options (eg,cafeterias, vending machines, healthy taste clubs) will com-plement provider efforts to implement lifestyle change. Asynthesis of older studies indicated that a point-of-decisionprompt to use the stairs instead of an elevator or escalatorresulted in a median increase in stair climbing of 53.9%.189
More recent studies have confirmed the positive effects ofsignage on stair usage in public buildings190 and have shownthat experimentally reducing the availability of escalators andmodeling more active behaviors increase stair use.217,218 Insummary, healthcare system policy and other policy changesare needed to increase the effectiveness of our evidence-based recommendations to improve diet and PA behaviors.
Where Do We Go From Here? Implicationsfor Future Research
Evidence suggests that cognitive-behavioral strategies are anessential component of interventions targeting dietary and PAbehavior change. We know that individual, group, andmulticomponent intervention delivery strategies are effective;however, we need comparative studies to demonstrate therelative strengths and weaknesses of implementing multicom-ponent strategies versus any single strategy. We also knowthat computer/Internet-based delivery strategies are effectivefor selected populations. However, the ability for newertechnologies such as text messaging and social networkingtools such as Health Vault, Twitter, and Facebook to facilitatedietary and PA change needs to be determined.
There are many other gaps in our current knowledge aboutpromoting lifestyle change. Comparative studies evaluating theeffectiveness and intensity of diverse interventions are needed toidentify the interventions most likely to succeed in both initiationand maintenance of diet and PA lifestyle changes. Optimalfollow-up strategies to maximize the duration of change needs tobe addressed in future studies. We do not know the specificdesign features that determine which interventions are mosteffective for whom (eg, young-old, male-female, high-lowsocioeconomic status) and at what cost. More knowledge abouttreatment receptivity or efficacy across different sex, racial,ethnic, or socioeconomic groups is needed. Many of the studies
reviewed included samples of predominantly well-educatedwhites, and several studies targeted blacks and Hispanics; morestudies that target other racial and ethnic minorities such asAsians, Native Americans, or Arab Americans are neededbecause these groups are also at risk for CVD.219 The majorityof studies reviewed (�57%) contained samples that were pre-dominantly (�70%) female. Although this representation ofwomen is an improvement from that reported in an earlierreview of 49 studies of compliance to pharmacological, exercise,nutritional, and smoking cessation therapies (85% male),187 westill do not know the extent to which lifestyle change interven-tions should be tailored to sex. The absence of males in most ofthe weight loss trials may reflect reluctance of some investiga-tors to mix sexes,29,36,57,109 as well as lower numbers of maleswho seek weight loss treatment or respond to recruitment effortsfor studies that include men.24,62 More research is needed onweight loss interventions in men, among whom the obesityepidemic is similarly rampant.220
Although the studies reviewed examined the influence ofbehavior change on surrogate end points such as lipid or BPchanges, few examined the influence of behavior change onCVD events, mortality, hospitalizations, or quality of life.221,222
More studies with longer-term follow-up of individuals who areable to maintain behavior change are needed to allow evaluationof these clinical end points.
The next generation of studies should also investigate howindividual interventions interact with the multiple levels ofenvironmental influences on PA and dietary behavior change.Both increased scope and detail of investigation are needed tounderstand the combined effects of individual behavior, health-care system, and sociocultural and environmental factors.Health-promoting community design,223 active-living communi-ties,224 and providing a healthier food environment should beincorporated into future studies to investigate multiple levels ofenvironmental influences on health behavior.
Lifestyle interventions often target constructs based onsocial cognitive theory (eg, self-efficacy, self-regulation[self-monitoring, goal-setting, feedback], social support, ob-servational learning) or the trans-theoretical model of change(eg, stages of motivational readiness). More evidence isneeded to determine whether one or the other theoreticalapproach may be better in specific circumstances.
Lack of reimbursement for therapies targeting dietary andPA lifestyle change is a barrier for healthcare providers. Inorder to establish a case for reimbursement, we need to betterunderstand the expected costs and cost-effectiveness of suchinterventions in the community. Future research must morecarefully examine effectiveness of behavior change strategiesin routine clinical practice, as opposed to efficacy trials thatexamine interventions under more structured ideal conditions.The efficacy of different behavior change strategies shouldalso be assessed in diverse practice settings with diversepopulations to understand generalizability and factors thatinfluence it. Finally, we need to understand how to translateand feasibly deliver these evidenced-based strategies intohealth practice, through delivery, dissemination, and diffu-sion research.
The AHA’s 2020 Goals include a new concept of cardiovas-cular health that directly incorporates metrics of lifestyle behav-
Artinian et al Promoting Physical Activity and Dietary Changes 433
iors, including diet and PA habits, as defining health.225 Whereasfurther research is needed on several aspects of individual- andgroup-based interventions to improve diet and PA, a sufficientevidence base now exists to incorporate several specific strat-
egies, as outlined in Table 4, into clinical practice. Thepromotion of these interventions should form a key com-ponent of strategies to achieve the AHA’s 2020 Goals andimprove the cardiovascular health of the population.
Disclosures
Writing Group Disclosures
Writing GroupMember Employment Research Grant Other Research Support
Speakers’Bureau/Honoraria
ExpertWitness
OwnershipInterest
Consultant/Advisory Board Other
Nancy T. Artinian Wayne StateUniversity
None None None None None None None
Gerald F.Fletcher
Mayo Clinic None None None None None None None
Philip A. Ades University ofVermont
None None None None None None None
JoAnne Banks Winston-SalemState
None None None None None None None
Kathy Berra Stanford University None None BoehringerIngelheim*; Gilead*
None None Knowledgepoint3602009 Lipids Online
ContributingAuthor*; AspirinMeasurementAdvisory Panel
NCQA/CPM/HEDIS2009*; NHLBI
ImplementationWorkshop 2009*
None
Lynne T. Braun Rush University None None None None None AHA LearningLibrary*; Heart
Profilers*
None
Lora E. Burke University ofPittsburgh
NIH† None Novo Nordisk* None None None None
J. Larry Durstine University of SouthCarolina
None None None None None None None
Linda J. Ewing University ofPittsburgh
NHLBI*; NIDDK*;NIH†; Pennsylvania
Tobacco Fund†
None None None None None None
Jerome L. Fleg NIH None None None None Bristol-MyersSquibb*
None None
Barbara J.Fletcher
University of NorthFlorida
None None None None None None Pritchett andHull Associates†
Laura L. Hayman University ofMassachusetts-
Boston
None None None None None None None
NancyHouston-Miller
Stanford University None None Gilead*; Pfizer*;Boehringer-Ingelheim*
None None None None
Suzanne Hughes Robinson MemorialHospital
None None None None None None Associate Editor,Cardiosource
(ACC)†
Laurie A. Kopin University ofRochester
None None Bristol-Myers Squibb*;Sanofi-Aventis*
None None None None
William E. Kraus Duke University None None None None None None None
PennyKris-Etherton
Penn StateUniversity
None California PistachioCommission†; General
Mills†; Hershey Foods†;National Cancer
Institute†; NationalCattlemen’s Beef
Association†; TomatoWellness Council†;Unilever†; United
Soybean Board†; USDepartment ofAgriculture†
None None None Health FitnessCorp*; Heinz*;
Merck*; ShapingAmerica Health*;
Unilever*
None
(Continued)
434 Circulation July 27, 2010
Reviewer Disclosures
Reviewer Employment Research Grant
OtherResearchSupport
Speakers’Bureau/
HonorariaExpert
WitnessOwnership
InterestConsultant/Advisory
Board Other
Vera Bittner University of Alabamaat Birmingham
NHLBI-HF ACTION Study(Multicenter Trial of
Exercise Training in HeartFailure)†
None American HeartAssociation*
None None None None
Timothy S. Church Pennington BiomedicalResearch Center
None None None None None None None
Barry Franklin William BeaumontHospital
None None None None None Smart Balance* None
Bonnie J. Spring NorthwesternUniversity
NIH† None None None None None None
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the DisclosureQuestionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or moreduring any 12 month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.†Significant.
Writing Group Disclosures, Continued
Writing GroupMember Employment Research Grant Other Research Support
Speakers’Bureau/Honoraria
ExpertWitness
OwnershipInterest
Consultant/Advisory Board Other
ShirikiKumanyika
University ofPennsylvania
None None None None None Weight Watchers,Inc*
None
Alice H.Lichtenstein
Tufts University None None None None None None None
Janet C.Meininger
University of TexasHealth ScienceCenter–Houston
NIH† None None None None Center for HealthPromotionResearch-
University of TexasSchool of Nursing
Austin, TX*
None
Todd D. Miller Mayo Clinic Lantheus MedicalImaging†;
Molecular InsightPharmaceuticals†
None None None None TherOx, Inc.*; TheMedicinesCompany*
None
DariushMozaffarian
Harvard University In discussions withSigma Tau,
GlaxoSmithKline,and Pronova for an
investigator-initiated trial of
fish oil and cardiacdisease
None None None None None None
Nancy S.Redeker
Yale University None None None None None None None
Eileen M.Stuart-Shor
University ofMassachusetts
Boston/Beth IsraelDeaconess Medical
Center
NIH† None None None None None None
Linda Van Horn NorthwesternUniversity
NIH† None None None None None None
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on theDisclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under thepreceding definition.
*Modest.†Significant.
Artinian et al Promoting Physical Activity and Dietary Changes 435
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KEY WORDS: AHA Scientific Statements � diet � lifestyle � activity,physical � skills, behavior change � reduction, cardiovascular risk �modification, lifestyle
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